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LIFE-CYCLE OF PLASMODIUM VIVAX. (AFTER GRASSI AND SCHANDINN.) 
The human cycle is above the transverse line, some rearranged by Kissalt and Hartmann. The 
C3'cle in the mosquito is beneath. 1 to 7, Schizogony: 1, sporozoite; 2, entrance of sporozoite; 3 and 
4, growth of the schizont; 5 and 6, nuclear division of the schizont; 7, formation of the merozoites; 
8, merozoites; 9a to 12a, growth of the macrogametocyte; 9b to 12b, growth of microgametocyte; 
13c to 17c. parthenogenesis of the macrogametocyte; 13a and 14a, maturation of macrogamete; 
13b and 14b, growth of the microgamete; 15b, microgamete; 16, fructification; 17, Ookinete; 18 to 
20, entrance of the Ookinete into the stomach wall of the mosquito; 20 to 25, sporogony; 22 and 23, 
nuclear multiplication in the sporont; 24 and 25, formation of the sporozoites; 26, passage of 
the sporozoites to the salivary gland; 27, salivary gland of the mosquito with sporozoites (Magn. 1 
to 17c, 1200 to 1; 18 to 27c, 600 to 1). Park: Pathogenic Bacteria and Protozoa. 



THE 



DISEASES OF CHILDREN 



BY 



HENRY ENOS TULEY, M.D. 

Professor of Obstetrics, University of Louisville, Medical Department; 
Visiting Physician Masonic Widows and Orphans Home; Secretary 
of the Mississippi Valley Medical Association; Ex-Secre- 
tary and Ex-Chairman of the Section on Diseases of 
Childiren, American Medical Association, etc., 
Louisville, Ky. 



ILLUSTRATED 




BALTIMORE 
SOUTHERN MEDICAL PUBLISHING COMPANY 

1909 






Copyright, 1909 

BY 

Southern Medical Publishing Co. 



WAVERLY PRESS 

WILLIAMS & WILKINS COMPANY 

BALTIMORE 



'CLA271415 



This Book is Affectionately Dedicated to 

My Wife, Whose Life Has Been 

a Constant Inspiration to 

Higher Endeavor 



111 



PREFACE. 

This book lias been written not for the specialist, but with 
the needs of the general practitioner and student in view, and 
the diseases of children have been described as they are seen 
by the busy practitioner in his daily rounds. 

Believing that the question of infant feeding is one of the 
most important which confronts us, much more space has been 
devoted to that subject than is given other important ones. We 
wish to interest the general practitioner in milk, its care and 
handling, the necessity for the formation of certified milk com- 
missions, and the establishment of milk depots where certified 
milk may be placed within the reach of the poor. 

Each disease is considered in a methodical manner. Special 
attention is given the dietetic and hygienic management, and 
the medicinal treatment is considered quite fully, with the repro- 
duction of many tried formulae. A collection of formulae, which 
have been found of value by the various authorities in pediatrics, 
is printed in the Appendix. These have not been printed as a 
suggestion that the disease be treated by rule, but that the com- 
binations of the various drugs indicated, as used by the recog- 
nized specialists of to-day may be seen. 

Chapters have been included on Diseases of the Eye, Ear, 
I^ose and Throat, and the Skin. 

Temperature charts have been reproduced in a number of 
places, with the hope that this valuable clinical aid will be 
more often employed in private practice than it is at present. 
A world of valuable data and statistics is lost because of the 
practitioner's failure properly to record bedside notes in daily 
visits to the private patient. We would encourage this feature 
of the work. 



VI PREFACE 

Thanks are herewith extended to Dr. Wni. Britt Burns, of 
Memphis, for the preparation of the chapter on Malaria; to 
Dr. Louis Frank and Dr. I. Lederman for valuable suggestions ; 
to Mrs. Mary West Fullenlove for painstaking preparation of 
the manuscript, and to the publishers for their many courtesies 
during the publication of the book. 

Henry Enos Tuley. 



CONTENTS 

Chapter I — Anatomy of Infants. 

Chapter II — The New-born. 
Asphyxia — Care of the New-born — Preparation for the Baby — Care of the 
Napkins — The Nursery. 

Chapter III — Diseases and Injuries of the New-born. 
Caput Succedaneum — Cephalhematoma — Hemorrhages — UmbiHcal Her- 
nia — Atelectasis — Icterus — Sepsis — Injuries — Mastitis — Starva- 
tion Temperature — Tetanus — Sclerema. 

Chapter IV — Growth and Development. 
Weight and Height — Dentition — Menstruation. 

Chapter V — Methods of Examination. 
Chapter VI — Therapeutics of Infancy and Childhood. 
Dosage — Varieties of Medication — The Bath — Pack — Stomach Washing — 
Irrigations — The Urine — Inunction. 

Chapter VII — Infant Feeding. 
Breast Feeding — Cow's Milk — Certified Milk — Bacteria in Milk — Tuberculo- 
sis — Epidemics Due to Milk — Morbidity and Mortality — Statistics Influ- 
enced by Milk — SteriHzation and Pasteurization — Percentage System of 
Infant Feeding — Condensed Milk — Diluents — Food Formulas — Disagree- 
ment of Milk Feeding — Difficult Feeding Cases — Artificial Foods. 

Chapter VIII — Diseases of the Nose, Throat and Pharynx. 
Acute Rhinitis — Chronic Rhinitis — Atrophic Rhinitis — Epistaxis — Nasal 
Polypi — Diseases of the Tonsils — Acute Catarrhal Tonsillitis — Follicular 
Tonsillitis — Uvuhtis — Peritonsillar Abscess — Retropharyngeal Abscess — 
Acute Catarrhal Laryngitis — Adenoids. 

Chapter IX — Diseases of the Ear. 
Diseases of the External Auditory Canal — Furunculosis — Impacted Wax — The 
Middle Ear — Acute Tubo-tympanic Catarrh — Acute Catarrhal Otitis 
Media — Acute Suppurative Otitis Media — Mastoiditis. 

Chapter X — Diseases of the Eye. 
Eye Strain — Blepharitis — Hordeolum — Conjuncti\4tis — Trachoma — 
Granular Conjunctivitis — Vernal Catarrh of the Conjunctiva — Diph- 
theritic Conjunctivitis — Phlyctenular Conjunctivitis — Ophthalmia Neona- 
torum — Pterygium — Phlyctenular Keratitis — Interstitial Keratitis. 



Vlll CONTENTS 

Chapter XI — Diseases of the Respiratory Tract. 
Foreign Bodies in Bronchial Tubes — Atelectasis — Acute Catarrhal Bronchi- 
tis — Chronic Catarrhal Bronchitis — Broncho-pneumonia — Lobar Pneu- 
monia — Pleurisy — Empyema — Gangrene of Lung. 

Chapter XII — Diseases of the Digestive System. 
Herpes — Diseases of the Tongue — Diseases of the Mouth — Ranula — Tongue- 
tie — ^Alveolar Abscess — Fistula of the Neck — Acute Esophagitis — Steno- 
sis of the Pylorus — The Feces — Gastric Disorders — Cyclic Vomiting — 
Gastro-intestinal Infection — Cholera Infantum — Enterocolitis — Consti- 
pation — Colic— Dilatation of the Colon. 

Chapter XIII — Intestinal Parasites. 
Oxyuris vermicularis — Ascaris lumbricoides — Tenia solium — Tenia medican- 
ellata — Ankylostomum duodenale. 

Chapter XIV — Surgical Conditions of the Intestine. 
Appendicitis — Intussusception. 

Chapter XV — General Diseases. 
Typhoid Fever — Rheumatism — Diabetes Mellitus — Tuberculosis — Pellagra — 
Malaria — Congenital Syphilis. 

Chapter XVI — Contagious Diseases. 
Measles — Rubella — Scarlatina — Varicella — Vaccinia — Variola — Pertussis — 
Parotitis — Diphtheria — Intubation. 

Chapter XVII — Diseases of the Circulatory System. 
The Heart — Congenital Heart Disease — Pericarditis — Pyopericardium — 
Endocarditis — Mitral Regurgitation — Mitral Stenosis — Aortic Sten- 
osis — Tricuspid Regurgitation — Tricuspid Stenosis — Treatment of 
Valvular Lesions — Acute Myocarditis. 

f Chapter XVIII — Diseases of the Blood. 

The Blood of Infancy and Childhood — Anemia — Pernicious Anemia — Chlo- 
rosis — Lymphatic Lukemia — Pseudoleukemia — Pseudoleukemia of 
Infants — Purpura — Hemophilia. 

Chapter XIX — Diseases of the Lymphatic Glands. 
The Thymus Gland — Acute Adenitis — Chronic Adenitis — Addison's 
Disease — Cretinism. 

Chapter XX — Diseases of the Genito-urinary System. 
The Urine — Albuminuria — Pyelitis — Renal Calculus — Perinephritis — 
Acute Parenchymatous Nephritis — Chronic Nephritis — Chronic Intersti- 
tial Nephritis — Tumors of the Kidneys — Hydronephrosis — Enuresis — 
Phimosis — Paraphimosis — Balanitis — Urethritis — Vulvo- vaginitis — 
Cystitis — Undescended Testicle. 



CONTENTS IX 

Chapter XXI — Nutrition Disorders. 
Athrepsia — Scorbutus — Rachitis. 

Chapter XXII — Diseases of the Nervous System. 

General Considerations — Convulsions — Chorea — Hysteria — Epilepsy — 
Disorders of Sleep — Multiple Neuritis — Obstetrical Paralysis — Infantile 
Paralysis — -Acute MyeHtis — Pottos Disease — Tumors of the Spinal Cord — 
Syphilis of the Cord — Disseminated Sclerosis — Hereditary Ataxia — He- 
reditary Spastic Paralysis— Progressive Muscular Dystrophy — Meningi- 
tis — Tubercular Meningitis — ■ Epidemic Cerebro-Spinal Meningitis — 
Encephalitis — Hydrocephalus — Chronic Hydrocephalus — Cerebral 
Palsies — Tumors of Brain and Meninges — Abscess of Brain — Intra- 
cranial Hemorrhage. 

Ch.apter XXIII — Diseases of the Skin. 

Intertrigo — Sudamina — Pediculosis — Scabies — Ringworm — Tinea 
Favosa — Impetigo Contagiosa — Pemphigus — - Eczema — Herpes — 
Pruritus — Urticaria. 

Appendix. 
Milk Modifications — Babies' Milk Fund Association Brochure — Refrigerator. 



CHAPTEE I. 

Anatomy of Infants. 

The infant's anatomy diifers from that of the adult in many 
essential points. The chief of these is the change which takes 
place in the circulation immediately after birth. These may 
be named as follows, probably in the order of their happening: 
Opening of the pulmonary arteries; closure of the foramen 
ovale, complete about the tenth day; disappearance of the Eu- 
stachian valve; obliteration of the ductus arteriosus, ductus 
venosus and the hypogastric arteries, the latter remaining pervi- 
ous from the internal iliac arteries to the bladder, known after 
birth as the superior vesical arteries. The umbilical vein and 
the ductus venosus close about the fifth day, the latter per- 
sisting in its impervious state as the round ligament of the 
liver. With the tying of the cord the hypogastric arteries and 
the vessels in the cord are obliterated. 

The child's head is very soft and compressible, the bones 
are ununited and separated by sutures; where the sutures 
coalesce are the anterior and posterior fontanelles. The anterior 
fontanelle, at the anterior superior end of the parietal bones is 
larger than the posterior and quadrilateral in shape. It closes 
during the second year. The posterior fontanelle at the poste- 
rior inferior ends of the parietal bones is triangular in shape 
and smaller. It closes by the end of the first year. 

As a result of moulding during birth the head in normal 
cases is much elongated from the chin to the occiput, and if a 
large caput succedaneum is present it is still further misshapen. 
Its normal contour is restored in a few days. The scalp is quite 
mobile, owing to its loose attachment to the aponeurosis. The 
frontal hone is divided into two equal parts by the frontal 

1 



2 THE DISEASES OF CHILDREN 

suture. The sphenoidal and temporal bones consist of three 
separate pieces each. The mastoid cells are not present. The 
hiferior maxilla is divided into two equal portions united by 
fibrous tissue at the chin. 

The infant's ear differs greatly from the adult's. At birth 
the axis of the meatus is directed upward, the canal being 
smaller at the inner end. The auricle is pulled downward to 
obtain a view of the tympanum. 

The Eustachian tubes in the infant are about half the length 
of the adult's ; they are straight, and nearly horizontal, and the 
pharyngeal opening is about on a level with the hard palate, 
and smaller, relatively, than in the adult. 

The nose is small in infancy and the respiratory space in 
the nares very limited. The nasopharynx is quite deep. It is 
vascular and rich in lymphoid tissue. The presence of this 
lymphoid tissue is a menace to infants as it becomes easily 
inflamed and swollen, obstructing the respiratory area. 

The spine is very flexible, the bones at birth are mostly car- 
tilaginous, the nuclei of ossification being present. Spina bifida 
results from a failure of the laminse to unite allowing a pro- 
trusion of the membranes of the cord or filaments of the cord 
itself. The upper extremities are much better developed at birth 
than the lower, the fetal circulation providing a venous blood 
to the lower extremities. 

The clavicle is one of the first bones to ossify. The ossifica- 
tion of the long bones begins in the center of the diaphysis. The 
bones of the thorax are mostly cartilaginous, hence, the elastic- 
ity of this portion of the body. Several centers of ossification 
are present in the sternum. The larynx is higher than in the 
adult, being about on tlie level with the axis, and a view of the 
epiglottis and vocal cords can frequently be had without the 
aid of a mirror. 

The trachea divides at about the third lumbar vertebra. The 
opening into the right lung is larger than the left, the right 
bronchus not having quite so wide an angle. 



ANATOMY OF INFANTS 3 

The lungs at birth are small and the air vesicles entirely col- 
lapsed. On removing the anterior chest wall of a still-born 
child the lungs do not fill the thoracic cavity and the heart is 
found uncovered^ the thymns gland extending nsnally below 
the base of the heart. As a result of the first deep inspiration 




FIG. 1. BIFURCATION OF BRONCHI; APEX BEAT OF HE.AJRT. 



the air vesicles are dilated, the Inngs expand, fill the cavity and 
cover the heart. The division of the right lung into three 
lobes is quite marked in the infant, with a deep fissure es- 
pecially posteriorly between each. The lower border of the 
right lung posteriorly, reaches the tenth rib on the right side, 
and to the eleventh rib on the left side. 



4 THE DISEASES OF CHILDREN 

The thymus gland is an organ but little understood. It is 
present in the new-born, often being relatively of great size, 
gradually growing smaller after birth. It may extend as low 
as the fourth rib, and above the suprasternal notch. It has two 
lobes, and may measure 2 14 by II/2 inches. Its undue develop- 
ment has been supposed to be the cause of some otherwise un- 
explained cases of sudden death. 

The bronchial glands are located around the trachea in its 
lower portion and extend around the bronchi at their bifurca- 
tion. These are normally quite small, but as a result of an 
infection may assume quite a large size. 

The fetal heart differs from that of the new-born in the 
presence of the interauricular opening, the foramen ovale and 
the Eustachian valve, which is supposed to guide the blood 
from the inferior vena o.ava through the right auricle into the 
left auricle. The cavities of the right side are larger than the 
left, the heart weighing about two-thirds of an ounce, at birth. 
With the change in the circulation after birth the heart assumes 
more the adult type, the left side becoming larger. The apex 
beat is felt about the fourth interspace farther to the left than 
in the adult. 

The fetal circulation is as follows : Leaving the placenta the 
blood flows through the umbilical vein to the umbilical open- 
ing, ascending to the under surface of the liver from there 
through the ductus venosus, a fetal structure, to the inferior 
or ascending vena cava. From the inferior vena cava the stream 
goes into the right auricle guided by the Eustachian valve 
through the foramen ovale into the left auricle. From the left 
auricle through the mitral orifice to the left ventricle; from 
the left ventricle to the ascending aorta, through the larger ves- 
sels of the neck to the brain and upper extremities. The blood 
returns, via the superior or descending vena cava, to the right 
auricle, being largely venous in character ; from the right auricle 
to the right ventricle, the pulmonary arteries being impervious, 
the blood is carried through the ductus arteriosus, a fetal struc- 



ANATOMY OF INFANTS 

ture, to the descending aorta. Throngh tlie descending aorta 
the blood flows as far as the iliac vessels, a portion of it going 
through the external iliac to the lower extremities, the rest of 
the blood going through the hypogastric arteries, branches of 
the internal iliacs, over the summit of the bladder and under 
the anterior abdominal wall to the abdominal opening where 
these vessels become the umbilical arteries. 

The umbilical opening may be patulous at birth and allow 
a protrusion through into the cord of a loop of the intestine, or 
there may be a separation of the umbilical ring after the stump 
of the cord falls off allowing a protrusion of intestine and the 
formation of an umbilical hernia. There have been a few cases 
reported where a coil of intestine had been included in a liga- 
ture which encircled the cord to tie the umbilical vessels. 

The stomach at birth is more like the dilated end of the esoph- 
agus than a separate organ itself, due to the pyloric end being 
pushed downward by the left lobe of the liver, causing it to 
assume more of the upright position. Regurgitation of its 
contents is very easy because of this. ~ The stomach at birth will 
hold about 1 ounce. The cardiac opening is located about 
opposite the first dorsal vertebra, the principal difference in the 
intestine is the relatively large size and length of the sigmoid 
flexure of the colon. 

The sigmoid flexure at birth is about as long as the colon 
itself, the sigmoid extending frequently much beyond the median 
line. Owing to the shallowness of the pelvis most of the sig- 
moid is in the abdominal cavity. 

The liver is one of the heaviest organs in the body at birth, 
its relative weight to that of the body being 1 to 18. Its 
growth and development are due to its receiving first the 
pure arterial blood as it comes from the placenta. The left 
lobe may extend much beyond the median line. 

The spleen is small at birth, lying usually under the ninth 
and tenth ribs, and cannot be felt upon palpation unless en- 
larged. The Jcidneys are about on a line with each other. 



THE DISEASES OF CHILDREN 



They are distinctly lobulated and may be joined^ forming a 
horseslioe kidney. On section a number of uric acid infarcts 
may be found. 

The suprarenal glands are relatively larger at birth than in 
the adult. They are highly vascular and may be the site of 




FIG. 2. CAPACITY OF INFANT's STOMACH (kELLEY). 

hemorrhage. (See report of case on page 25.) The male uretJira 
will average 2 inches in length and shows quite a distinct con- 
striction at the meatus. The fossa navicularis is relatively 
larger than the rest of the urethra and may be the site of the 
formation of a concretion or stone in late infancy. 



ANATOMY OF INFANTS 




FIG. 3. 




FIG. 4. 



THE DISEASES OF CHILDREN 




ANATOMY OF INFANTS 9 

The corona glandis is tightly covered by the prepuce, fre- 
quently adherent, with an accumulation of smegma behind the 
corona glandis. 

The testicles in the embryo are found in the abdominal cavity, 
below the kidneys, in the lumbar region. A± about the eighth 
month they descend and pass out into the scrotum through the 
inguinal canals. 

A child whose testicles are retained within the canal or cavity 
is called a cryptorchid, if only one has descended, a monorcJiid. 

The uterus at birth is small, about 1 inch in length; the 
ovaries are found in the lumbar region in intrauterine life, and 
at birth are as low as the brim of the pelvis. It is estimated 
that upwards of 75,000 ova are in each ovary at birth. 

The relative weight of the brain at birth to the body is 1 to 8. 
The color is quite pale and contains a larger percentage of 
water than the adult brain. 

HETEEOTAXIA. 

Irregular malpositions of viscera are occasionally observed 
in routine practice. These abnormalities have been exhaustively 
studied by Ballantyne, Osier, Ameill, Royer and Wilson. 

The usual form observed is a complete transposition, of either 
the thoracic or abdominal organs or both. 

Among the remarkable cases on record (Arneill^ reporting 
300 collected from the literature) are maintenance of fetal 
vascular conditions after birth : lobulated spleen or multiple 
spleens; one kidney; transposition of the cavities of the heart; 
of the lungs, liver and spleen. 

The fetal condition of the heart can be made out by physical 
examination. The other transpositions may not be suspected 
until found postmortem, and unless the heart is involved the 
child may reach adult life, with involvement of the heart these 
children rarely reach puberty. 

* American Journal Medical Sciences, November, 1902. 



CHAPTEK II. 

The E^ew-Born. 

As soon as the child's head is born, and before the birth of 
the body, feeble attempts are made at inspiration. At this time 
the mouth should be wiped out promptly and freed of the mucus 
and fluid which it contains in order to prevent its being as- 
pirated into the bronchial tubes, with the first deep inspiration. 

Reacting to the stimulus of the air upon the skin, the first 
inspiration is taken and the air vesicles are dilated. The skin 
quickly changes from a pallid or bluish color to the normal 
red, and the child cries lustily. The respirations at first are 
shallow, often slightly irregular, and they are of the abdominal 
type. The chest soon becomes fully expanded and the number 
of respirations which at first was 60 or 70 to the minute will 
average about 40 at the end of the first hour. 

ASPHYXIA. 

Where insufficient air has entered the lungs of the new-born 
to dilate the air vesicles the child is still-horn. When some air 
does enter the lungs and for any reason there is an interference 
with the proper interchange between oxygen and carbon dioxide, 
the condition is called asphyxia. 

Forms. Asphyxia may be intrauterine. This form is caused 
by any interference with the uteroplacental circulation; as a 
premature or accidental separation of a portion of the placenta ; 
knots in the cord, too tight loop or loops of the cord around the 
child's neck ; long-continued labor from any cause ; compression 
of the cord by the after-coming head ; compression of the fetal 
brain by forceps operation. 

Intrauterine asphyxia may be foretold by the premature 

10 



THE NEW-BORN 11 

escape of meconium in vertex presentations and by an inter- 
ruption in the beat of the fetal heart, either very rapid or very 
slow heart sounds. In interference with placental respiration, 
the blood of the fetus is surcharged with carbon dioxide, an 
increased intestinal peristalsis and a relaxation of the sphincter 
occurs, allowing escape of the meconium. In breech presenta- 
tion, the escape of meconium is from pressure causes entirely, 
and is of no significance. 

If premature respiration occurs before the birth of the head, 
liquor amnii and mucus may be aspirated, which will mechan- 
ically act as a cause of asphyxia. 

The persistence of the intrauterine apnea after birth con- 
stitutes the postnatal form of asphyxia. The chief cause of 
this form is an injury to the respiratory centers by prolonged 
labor; prematurity, the thin chest walls making it impossible 
for the lungs to dilate because of external atmospheric pressure, 
a general atelectasis following in these cases. 

Symptoms. In the intrauterine form of asphyxia, the child 
is born limp and the skin is pale or blue. Two forms are gen- 
erally referred to, asphyxia livida and asphyxia pallida, the 
latter being the most profound. In the mild cases there is a 
very feeble intake of air, noted by slight movement of the dia- 
phragm, strong umbilical pulsation and muscular action of 
the face and nose. If improvement follows, the respirations 
will become more regular and less spasmodic, the color will 
improve and the child will utter a feeble whine or cry. 

Prognosis. The progTiosis in all cases of asphyxia is very 
grave. Atelectasis is always to be feared. If the child does not 
nurse well, has a persistent subnormal temperature and pro- 
gressive and rapid loss in Aveight, the prognosis is more grave. 
As long as there are any heart beats to be heard one should 
persist in efforts at resuscitation by artificial respiration. 

Treatment. A basin or tub Avhich will hold enough water 
to completely cover the child's body, should be part of the equip- 
ment of every delivery room, as frequently respiration will be 



12 THE DISEASES OF CHILDREN 

stimulated by immersing the child in water at a temperature 
of 105° or 110° Y., and occasionally allowing a small quantity 
of cold water to trickle over its chest or plunging it for a second 
in cold water. If this fails^ resort should be had at once to 
the use of one of the methods of artificial respiration. 

A soft catheter may be introduced into the trachea and mucus 
aspirated through it, if the obstruction seems to be of that 
nature. The suspension of the child by its feet, and flaggella- 
tion of back and buttocks serve to allow drainage from the 
hmgs, stimulates the medulla by rush of blood ; by gravity and 
by reflex action through the skin, aids in respiration. It should 
be then plunged into the hot bath at once. 

The Byrd-Dew method can be used to advantage with the 
child immersed in the Avater. This method consists in holding 
the child upon its back in the palms of the hands, the head 
supported by one hand. Expiration is produced by bringing 
the pelvis toward the chest, arching the spine backward and 
compressing the lungs. Inspiration is produced by raising the 
ulnar sides of the hands, thus arching the spine forward. At 
the same time the head is allowed to fall back thus straighten- 
ing the trachea and aiding inspiration. 

With all the methods of artificial respiration, mouth to mouth 
insufflation is of benefit as it dislodges mucus concealed in the 
nasopharynx and forcibly dilates the air vesicles. The child's 
mouth is covered with a piece of gauze, the operator places his 
lips to the child's and blows air into the child's mouth. This 
may be repeated once or twice, a fresh piece of gauze being 
used or a fresh area covering the mouth. 

Artificial respiration should not be used oftener than thirty 
times to the minute. 

In Sylvesters method the child is placed upon its back, a 
folded towel under its shoulders and chin raised. The operator, 
standing at the head, draws its arms over its head for inspira- 
tion, and for expiration carries them down over the chest, at 
the same time making pressure on the chest wall. 



THE NEW-BORN 13 

In Schultzes method the child is supported with the index 
fingers in the axilla with its back to the operator. Expiration 
is produced bj raising the child and allowing the feet to fall 
forward over the face, thus compressing the diaphragm. Inspira- 
tion is produced bj allowing the child to fall forward into the 
first position, with the head fully extended, thus straightening 
the trachea. 

Labor de has suggested that rythmic traction on the tongue, 
acting through the recurrent laryngeal nerve, may stimulate 
respiration. 

Dilatation of the sphincter ani with the finger is a stimulant 
to respiration, and should be used in connection with the other 
methods. 

CARE OF THE NEW-BOEIST. 

Authorities difl:er as to the proper time to ligate the cord. 
The child unquestionably has a better start if all of the blood 
in the placenta can be utilized in its own vessels after birth, 
hence, ligation of the cord, when tlie pulsations have ceased, 
at about 10 inches from the child's abdomen, provided respira- 
tion has been prompt, gives the child this advantage. The cord 
is ligated 2 inches from the abdomen and a second ligature is 
applied, between which the cord is cut. The ligature material 
should either be a rubber elastic band, tape or very heavy silk. 
By using a rubber band which can be applied by means of one 
of several applicators on the market, continuous pressure is ex- 
erted on the vessels as the AATiarton's jelly atrophies, and hemor- 
rhage from the cord prevented. If tape or silk is used the 
cord should be frequently inspected during the first hour or 
two after birth to guard against hemorrhage. The cord may 
be dressed with a piece of sterile gauze 3 inches square, cut half 
across its middle. The cord is drawn through this cut and 
over it can be poured a dressing composed of balsam of Peru 
and castor oil,^ or a powder composed of one part salicylic acid 

* Balsam of Peru, iTp. 20; castor oil, one ounce. 



14 THE DISEASES OF CHILDREN 

and three parts of boracic acid. Over the cord is then placed an 
uncut piece of gauze and all is confined by a flannel binder 
6 inches wide, applied snugly but not tightly. This dressing 
is not removed except it be to renew the oil or the powder until 
the cord drops off, which usually occurs between the fourth 
and seventh days. I have seen one cord remain attached for 
18 days. If at the end of 10 days the vessels are still attached 
a ligature sliould be tied close to the umbilicus and the stump 
cut away. The umbilicus should be left perfectly smooth and 
dry after the cord drops off; if moist, a few applications of 
2 per cent solution of nitrate of silver and a drying powder will 
usually suffice. The flannel binder is only w^orn for the purpose 
of preventing an accident to the cord before it separates, and a 
knit binder is substituted for it at the end of two weeks. 

Too frequently a new-born child is neglected by the attending 
physician. As soon as the cord is cut, it is given to the nurse, 
and not again looked at. Every child should be carefully in- 
spected by the physician before it is dressed. Its mouth should 
be examined for presence of cleft palate ; extremities for de- 
formities ; genitals and anus for abnormalities ; scrotum for the 
presence of the testicles. At the end of six or eight hours, 
inquiry should be made to learn whether the bladder and rectum 
have been evacuated. If the passage of urine seems painful, 
this may be due to a constricted, pinhole prepuce, or to the 
passage of uric acid sand with the urine, the latter being present 
on the napkins and easily seen. If no meconium has been 
passed the rectum should be inspected for an imperforate anus, 
and if this is found appropriate measures taken at once for its 
relief. 

The skin is covered with a cheesy-like substance called vernix 
caseosa. This is accumulated to a considerable extent in the 
flexures and folds of the skin. This substance can be easily 
removed, if disintegrated by the application of some oily sub- 
stance. Vaseline, olive oil or unsalted lard is rubbed over the 
child's body thoroughly, the face being wiped off with a greased 



THE NEW-BORN l5 

piece of gauze. A shirt and napkin are applied and the child 
wrapped in a blanket and laid upon its right side in either a 
crib or bassinet. A useful bassinet can be made of a wicker 
clothes basket which has been padded and a pillow placed in 
the bottom upon which the child is laid. At the end of four or 
five hours the child is given its first bath while lying upon the 
nurse's lap, water at the temperature of 100° F. is used and the 
v^ernix removed with a soft cloth without violence. The skin 
is thoroughly dried and pure talcum used in the folds and 
flexures of the skin. 

Eyes. Crede's treatment of the eyes for the prevention of 
ophthalmia neonatorum should he used in every new-horn hahy's 
eyes. E^o patient can positively be said to be free from gono- 
cocci, and if the treatment is reserved for those cases where 
there is a history of a purulent vaginal discharge in the mother 
before delivery, many severe cases will be encountered. The 
treatment is of itself entirely harmless, and an absolute prophy- 
lactic. One or two drops of a 2 per cent solution of nitrate of 
silver are dropped into each eye, at the outer canthus. E"ormal 
salt solution is then squeezed into each eye from a pledget of 
gauze or medicine dropper, to neutralize any excess of the silver. 
If any irritation results from this treatment it is very slight and 
transitory. Other salts of silver have been suggested as a sub- 
stitute for the nitrate, as argyrol, but none are as effective as 
the one first suggested by Crede. 

Mouth. As a routine the mouth should be washed with 
boracic acid solution before and after each nursing, before nurs- 
ing to protect the mother's nipple, and after, to remove any 
particles of milk remaining in the folds of mucous membrane. 
The development of thrush or sprue is an evidence of careless- 
ness and neglect. A swab of soft sterile gauze or absorbent 
cotton is made on the end of the little finger and wet with 
boracic acid solution, and the whole of the inside of the mouth 
carefully and gently swabbed. Violence should be guarded 
against as an abrasion of the mucous membrane from too vig- 
orous rubbing may be the site of an infection. 



16 THE DISEASES OF CHILDREN 

Bathing. The child should be given a daily bath upon the 
lap until the cord drops off, the baby being partly covered v^ith 
the bath blanket. Only pure castile soap should be used in the 
bath. When the cord has dropped off and the navel is healed, 
the baby should be soaped while in the lap then immersed in a 
baby's bath tub. The tub can be made collapsible, of rubber 
sheeting, supported on legs of the proper length, so as to make 
it the correct height to be comfortable and convenient for the 
mother or nurse. If a small white porcelain tub is used it 
should be placed on a chair or stool. A folded bath towel should 
be laid on the bottom of the tub, to prevent the child slipping. 

The temperature of the water should be 100° F. After the 
baby is a month old the water should be cooled to 90° F. before 
the child is removed. When removed from the water it is 
wrapped in the bath blanket, carefully dried, the buttocks and 
flexures powdered, and dressed immediately. The bath should 
always be given before nursing, never just after being fed. It 
may be found most convenient and comfortable to the child to 
give the bath just before the last feeding at bed time. In hot 
weather a second bath may be given at bed time. 

A folded napkin can be placed under the child to soak up 
any urine which penetrates the first one. Rubber impkiiis 
should never be used. 

Buttocks. The first discharge from the bowels is meconium. 
It is composed of epithelial cells and biliary salts, is black and 
of the consistence of tar. It is difficult to remove from the 
skin, and when it remains in contact with it for some time 
irritation and maceration take place, and an intertrigo follows. 
An intertrigo is always the sign of carelessness. As soon as 
soiled the napkin should be removed and the skin very gently 
washed vdth a soft cloth and water, without soap, and carefully 
dried and powdered. 

Genitals. The female genitals need but little care except 
ordinary cleanliness and prompt removal of soiled napkins 
both day and night. The possibility of the development of a 



THE NEW-BORN 17 

vulvovaginitis, either simple or specific, should be borne in 
mind. The treatment of the latter is referred to in another 
place. 

Indiscriminate and universal circumcision of a male infant 
should not be advocated. If, when the baby is a month old, the 
prepuce is reflected, adhesions broken up and the smegma re- 
moved, and vaseline placed well around the corona glandis, the 
necessity for circumcision is averted. This will prevent the 
pinhole opening and long prepuce so frequently seen in boy 
babies in whom this precaution has been omitted. This reflec- 
tion should be repeated once every second day for a week, then 
once a week, for the sake of cleanliness. I have seen one case 
in which an infection occurred after the first reflection at the 
site of one of the abrasions where a rather tight adhesion had 
occurred, and considerable pus accumulated behind the corona, 
this being possible as the mother had failed to again completely 
reflect the prepuce to cleanse it. The mother should be cau- 
tioned in regard to the possibility of a paraphimosis developing 
from allowing a prepuce to remain reflected behind the corona 
too long at a time. 

^o infant should ever be allowed to sleep in the same bed 
with its mother. 

PREPAEATION FOR THE BABY. 

The baby's basket should be prepared some weeks before 
birth, and the following articles for it are suggested: 

Pin-cushion containing three sizes of safety pins. 

Soft hair brush. 

Soap box with white castile soap. 

Talcum powder in box with perforated top. {Powder Puff is nnhygienic.) 

White vasehne in tube. 

Benzoinated oxide of zinc ointment. 

Bath thermometer. 

Hot-water bag, two-quart, with removable flanellette bag with draw 

string. 
Saturated solution of boracic acid. 
One pair blunt scissors. 



18 THE DISEASES OF CHILDREN 

Absorbent cotton, wrapped in small towel. 

Soft towels made of old damask. 

Apron bath blanket of outing flannel made of two thicknesses sewed 

together at the top only. 
Wooden tooth picks to be wrapped with absorbent cotton at one end to 

be used as swab for cleaning nose. 
Two or three thin flannel bands, six inches wide. 
Soft Hnen of double thickness, or cheese cloth for wash cloths. 
Squares of sterile gauze for washing mouth. 
Medicine dropper. 

A box or special drawer should be provided for the baby's 
clothes. The outfit should consist of the following : 

Four dozen napkins made of cotton birdseye, two sizes, 20 inches and 

24 inches wide. Either square or double. 
Six flannel skirts. 
Four silk and wool shirts. 
Four knit bands. 
Four outing flannel gowns. 
Nine white slips, nainsook or longcloth. 
Three white cambric petticoats. (To be worn only in summer, and not 

with flannel ones.) 
Two white baby blankets or comforts. 
Two knitted sacks. 

Two or three quilted pads for baby's bed, one yard square. 
One cloak — two caps — one veil. 
Two pieces rubber cloth, one yard square. 
Fine hair pillow, 10 x 12 in. for buggy. 
Six pillow sUps. 
Six sheets for bassinet. 
Skirt stretcher. 

Stocking stretcher. For drying these garments without shrinking them. 
One flannel bag for tying about child's waist when out of doors. 

Much help can be had in making the baby's clothes by using 
Butterick's patterns, set 'No. 7080. 

CARE OF I^TAPKINS. 

Too great emphasis cannot be laid on the importance of 
careful washing of the napkins, both when soiled with a move- 
ment from the bowels and when wet with urine only. They 
should be washed with soap and soda, followed by several rins- 



THE NEW-BOKN 19 

ings in cold water, and dried out of the nursery, folded smooth 
by hand and not ironed, as ironing renders them less absorbent. 
I have seen several cases of severe eczema, limited to the part 
of the body covered by the napkin, where inquiry developed the 
fact that the napkin was being used after being wet three or four 
successive times and simply dried without washing. 

As soon as a napkin is soiled it should be taken to the bath 
room or closet and the movement scraped off with a knife kept 
for that purpose, wiping the scrapings on a piece of toilet paper 
and throwing it in the closet. The diaper is then put in a 
covered porcelain bucket, Avhich should be provided, containing 
a weak formaldehyde solution or a 1 to 100 carbolic acid solu- 
tion in which the soiled napkins can be placed until washed. 

THE NURSERY. 

The nursery should be a bright cheery room, with an open 
fireplace for winter heating, if possible. The temperature 
should not be over Y0° F., and the air should be changed at least 
once daily, first removing the child and opening all windows for 
a half to one hour. It should have not less than 1000 cubic 
feet of air space, and more if possible. Emphasis should be 
laid upon the importance of a moist air in steam-heated or hot- 
air-heated houses. 

The w^alls should by preference be painted and the floor un- 
carpeted, either hardwood or painted. This makes it possible 
for the floor to be wiped up and not swept, thus avoiding dust. 
The use of the Clean ator or other compressed air-cleaning 
devices in private houses should be recommended, where there 
are children, especially. There should be plenty of light, when 
the child is awake, with dark shades to darken the room when 
asieep, and the room should be at least 5° cooler at this time. 
In favorable weather the child can sleep in its buggy out of 
doors, protected from the wind and its eyes from the light. 

The skin of the new-born is very delicate, and is covered with 



20 THE DISEASES OF CHILDREN 

lanugo, a fine downy haii^ whicli is soon rubbed off. There is 
frequently desquamation of the skin, either general or on various 
parts of the body. 

Most infants have a rather heavy suit of hair, at birth, and 
during the first three months this is usually rubbed off, first 
on the back of the head, where it comes in contact with the 
bed, and this is replaced by a finer and softer growth. 

In the new-born the temperature is usually elevated 1° or 
2°. A large number of observations made by Edwards, Keat- 
ing and Holt, have demonstrated that the temperature in 
infants, between ages of one and twelve months, ranges be- 
tween 99° r. and 99.5° F., and that only a temperature of 
100° F. or over should be considered abnormal. A continuous 
subnormal temperature is one of the best indications of poor 
nourishment. 

If no deformity exists, an infant should pass urine during 
the first two or three hours after birth. The first secretion is 
usually clear, but it may become turbid, or contain a deposit 
sufficiently thick to stain the napkin, or distinct particles of 
uric acid sand may be passed. Some pain is usually exper- 
ienced when the latter is passing. The urine later in infancy 
is very light in color and of low specific gravity. 



CHAPTER III. 

Diseases ai^d Ijs^jtjries of the E'ew-Bokn'. 

Caput Succedaneum. This is a collection of blood serum in 
the cellnlar tissue of the presenting part of the child. It is due 
to a constriction of the veins of the skin by the bony pelvis 
preventing a free return of the blood and allowing an escape 
of the serum into the cellular tissue. It is present at birth, 
and in vertex presentations, the scalp may be thick enough to 
make it impossible to detect any of the sutures or fontanelles. 
The extravasation has usually been absorbed by the end of the 
second day, and the scalp and head have a normal appearance. 

Cephalhematoma. This is an extravasation of blood from a 
ruptured capillary between the periosteum and the bone. It 
usually does not occur until the third or fourth day, and is 
most frequently found over one or both parietal bones. The 
extravasation of blood is limited entirely to the bone over which 
it occurs, as the periosteum is bound dovm to the edges of the 
bone. If over both parietals, there is a deep sulcus between, 
corresponding to the sagittal suture, and looking at the head 
from behind it has the appearance of two half oranges under 
the skin on opposite sides. 

Cephalhematoma must be differentiated from Jiernia cerebri. 
In the latter the tumor is a pulsating one and in cephalhematoma 
it is not. Crying will increase the tension of a hernia but 
causes no change in the cephalhematoma. Cephalhematoma is 
not always due to injuries sustained in prolonged, natural or 
instrumental deliveries, in vertex presentations. As an instance 
may be mentioned one case, under my observation, of double 
cephalhematoma in a breech presentation, without delay in the 
birth of the after-coming head. 

21 



22 THE DISEASES OF CHILDREN 

Treatment. The temptation is to interfere in cases of cephal- 
hematoma but under no circumstances should they be interfered 
with. If protected from injury from pressure, nature takes 
care of them by absorption, and in the majority of cases after 
being absorbed, no trace of them can be found, unless it be a 
small ridge at the extreme edges of the tumor. 

Umbilical Hemorrhage. Hemorrhage from the cord may 
occur before it drops off, either from a loosely applied ligature 
or from the vessels being cut through by a small ligature being 
tied too tightly. Both of these accidents can be prevented by 
the use of a rubber elastic ligature, in the form of a small 
rubber ring of caliber smaller than the circumference of the 
cord, which is stretched and slipped over the severed end of the 
cord, by one of the appliances for that purpose. A ligature of 
this kind exerts continuous pressure on the vessels as the Whar- 
ton's jelly dries, and bleeding is more effectually prevented 
than can possibly be done by any other means. 

Hemorrhage may occur from the umbilicus after the cord 
has dropped off, and in all such cases there is a tendency to 
hemorrhage as is found in hemophilia or the "bleeders." 

Pressure upon the bleeding vessels at this point is very diffi- 
cult to accomplish. If there is but a small amount of oozing, 
the application of per sulphate of iron may control it. Needles 
carried under the umbilicus at right angles, and wrapped with 
a figure of eight suture should be tried in the severer cases. 

Granulating Umbilicus. After the separation of the cord, one 
or more of the vessels may be left as a small granular spot, from 
which there is a serous, or seropurulent discharge, an eczema of 
the skin of the umbilicus sometimes following. 

Treatment. The application of a solution of nitrate of silver, 
30 or 40 grains to the ounce, followed by a dry, absorbent dress- 
ing, as powdered boracic acid and starch, equal parts, this being 
repeated once daily. 



DISEASES AND INJURIES OF THE NEW-BORN 23 

!N'ew-borii babies are specially prone to develop hemorrhages, 
and because of the indefinite knowledge to-day of the true 
pathology of the condition, the symptom complex is now called 
in general terms, ''hemorrhages of the new-born." Formerly 
an attempt was made to describe each case according to the loca- 
tion of the hemorrhage, in this way having a number of terms, 
descriptive of the same general underlying disease. Kling, 
Genrich and Runge, quoted by Koplik, state that hemorrhagic 
disease in the new-born occurs about once in 1000 cases. 

Etiology. The etiology of the condition is obscure ; but in 
view of the fact that fever is a prominent symptom in most 
cases, the consensus of opinion is that the most frequent causa- 
tive factor is a general septic infection. The new-born develop 
sepsis easily and the entrance to the system of the offending 
organisms may be at many points, the gastrointestinal tract, 
the mouth, the genitourinary tract and the umbilicus being the 
most frequent portals. Gartner claims to have found bacilli 
in the feces in cases of melena, proving his theory that this 
form of hemorrhage is a coccal sepsis. In Winckel's disease, 
a condition closely similar, streptococci and bacilli have been 
found in various organs and the blood. The changes whicli 
occur in syphilis, which has been named as a cause, are in the 
blood vessels rather than in the blood itself. 

Among the other causative factors have been mentioned pre- 
maturity, atelectasis, deformity of the heart, persistent foramen 
ovale or ductus arteriosus, ulcer of the stomach and intestine, 
the latter due to a venous stasis, followed by a thrombosis ; fatty 
degeneration of the arterioles; extreme delicacy of the blood 
vessels; congenital obstruction of the portal venous system; 
congestion from pulmonary, cardiac or hepatic disease ; ex- 
cessive secretion of gastric juice resulting in partial digestion 
of the mucosa of stomach and intestine, congenital hemophilia 
and the great changes taking place in the circulation incident 
to birth. 

Hemorrhages in the new-born may take place from any organ 



24 THE DISEASES OF CHILDREN 

and the hemorrhage may occur before birth or subsequently. 
When postnatal, it usually occurs within the first three days 
after birth. 

In Dr. Townsend's 50 cases, quoted by Eotch, he gives the 
following location of the hemorrhages: 

Intestines 20 Pleural Cavity 2 

Stomach 14 Lung 1 

Nose 12 Thymus Gland 1 

Mouth 14 From Gastro-enteric tract, nose, 

Umbilicus 16 umbilicus accompanied by ecchy- 

Ecchymoses in Skin 21 mosis of skin 3 

Scratch of Skin 1 Gastro-enteric tract alone 19 

Cephalhematoma 3 From umbilicus alone 3 

Meninges 4 Ecchymoses of skin alone 6 

Abdominal Cavity 2 

Holt gives Hitter's statistics in 190 cases as follows: Hemor- 
rhage from the umbilicus, 138 (umbilicus alone, 97) ; intes- 
tines, 39; mouth, 28; stomach, 20; conjunctivse, 20; ears, 9. 

I have seen one case of hemorrhage into the suprarenal gland, 
a number of cases of cephalhematoma, both single and double, 
and the case shortly to be reported, of melena, or hemorrhage 
from the stomach and intestine. In the case of hemorrhage in 
the suprarenal capsule, reported in full in the Archives of 
Pediatrics, N'ovember, 1892, the right suprarenal gland was 
distended with blood to the size of an orange, and blood clots 
were found behind the kidney and in the free peritoneal cavity. 
The diagnosis was not made in this case during life, the most 
prominent symptom being a profound jaundice. The hemor- 
rhage was found postmortem. 

Hemorrhage from the gastrointestinal tract may occur inde- 
pendently of bleeding from any other organ and is called 
melense. If from the mouth alone, the quantity of blood lost 
is usually small, if from the stomach large quantities may be 
vomited or passed from the bowel in form of clots. As stated, 
it has been thought by different observers to be due to an ulcer- 
ation of the mucous membrane^ following septic emboli of its 



DISEASES AND INJURIES OF THE NEW-BORN 25 

vessels, a digestion of the membrane by a hyperacid gastric 
jnice, or to a general pyogenic septic condition. Like the other 
forms it nsnally occurs during the first three days, and with 
great variety as late as the ninth day. The child may first 
vomit some red blood, followed soon afterward by a coffee-ground 
vomit, or blood may first be noticed in the discharges from the 
bowel. The meconium, being very dark in color, may cause 
blood in the actions to be overlooked, unless it is passed in large 
clots. If passed in considerable quantity the napkin at the 
edge of the mass wdll be stained a reddish color, or if blood 
is suspected a microscopic examination will reveal the blood 
corpuscles. It should be borne in mind, before a diagnosis of 
hemorrhagic disease is made that the source of the blood may 
have been a fissured nipple, or blood from the nose which has 
been swallowed. I have seen one case which caused considerable 
uneasiness until it was finally decided that the source of the 
blood was from a cracked nipple. 

Prognosis. The prognosis in hemorrhagic diseases of the 
new-born varies according to the site of the bleeding. Taken 
as a whole the mortality is given by various authors differently : 
Townsend's cases 62 per cent, and in another series of 709, 79 
per cent; Williams places it at 60 per cent; Holt states that no 
observer has seen more than one-third of his cases recover. 

The following history is given as illustrative of that form 
of hemorrhage known as melena : 

Child of III Gravida. First labor instrumental, occiput 
posterior, forceps rotation. Second labor normal, but pro- 
longed. Third labor began at 12 midnight, birth at 1 p. m. 
following day. Vertex presentation ; first position ; mech.anism 
and labor normal. Child, female ; weight, 9 pounds 8 ounces ; 
normal in every way ; primary respiration prompt and normal ; 
no cyanosis ; nursed vigorously when put to the breast. An 
abundant supply of milk appearing on the third day. On the 
third day at noon the child vomited red blood, sufficient in quan- 
tity to stain its clothes through and through. Shortly after this 



26 THE DISEASES OF CHILDREN 

a very large movement of meconium was passed containing red 
blood, very easily distinguistied in the black meconium mass. 
Child pale and blue around the nose, pulse weak and rapid; 
refused to nurse after vomiting blood, the nursing being dis- 
continued after hemorrhage was reported. 

Eor two days vomiting of blood and hemorrhage from the 
bowels occurred, the latter quite profuse and being passed in 
masses of clots. 

After treatment with subcutaneous injection of gelatin solu- 
tion, 2 per cent, described below, the child made a good recov- 
ery; at the end of the second week it had regained its birth 
weight and continued to thrive. 

Treatment. Various methods of treatment have been sug- 
gested by different authors. Koplik suggests the cold coil ; er- 
gotin, one-half to three-fourths grain subcutaneously ; Henoch 
suggests one drop of liquor ferri sesquichloridi in barley water 
every hour; Williams suggests gallic acid, gr. i, every three 
hours ; oil of turpentine, m. i, in mucilage every hour ; extract 
of krameria gr. ii, every two or three hours, or an injection 
into the bowel of an infusion 4 to 5 ounces, and calcium chloride 
to increase the coagulability of the blood. 

The subcutaneous injection of gelatin employed in the case 
reported was followed by very prompt recovery. 

The English gelatin is used, as the ordinary commercial gel- 
atin has been found contaminated with the tetanus bacillus. 
Two sterilizations are made in order to be sure this organism is 
destroyed. An ordinary antitoxin syringe or aspirator, without 
too large a needle can be usd for the injection. The cellular 
tissue of the back can be used, the solution warmed, and 20 cc. 
can be slowly injected. 

P. Emile Weil* while studying hemophilia began the use 
of fresh animal sera injected either intravenously or subcu- 
taneously as a means of controlling or preventing hemorrhage. 
These observations brought out the fact that the serum from 

* Leary; Boston Medical and Surgical Journal., vol. clix, no. 3. 



DISEASES AND INJUEIES OF THE NEW-BORN 27 

horses, rabbits, man and cattle had the power of controlling 
hemorrhage by increasing the coagulability of the blood; that 
the serum from beef possessed too much toxicity ; that the serum 
should be less than two weeks old; that the dose was 15 to 30 
cc. ; it is of service locally in causing clotting ; that the increased 
coagulability persisted for a period of from 15 days to several 
weeks; that sporadic hemophilia and acute purpura gave the 
most definite cures. 

As long as there is any bleeding from the stomach food can- 
not be given in this way, but it can be given by nutrient enemata. 

UMBILICAL HEENIA. 

Etiology. The failure of the umbilical ring to firmly unite 
after the cord drops off is the chief cause. Contributory cause 
is the continuous crying of babies subject to colic, hunger, etc., 
or who strain from constipation. The tumor varies in size from 
a small knuckle to a large protuberance. 

Contents. The contents of the sac may be omentum alone 
or gut, with or without omentum. 

Treatment. This is either surgical or palliative. Cures can 
be obtained by the use of an adhesive strip 2 inches wide, and 
long enough to reach to the anterior axillary line on each side. 
The hernia is reduced, a pad is made of a button mould, cov- 
ered with adhesive plaster, or of several thicknesses of plaster, 
and placed over the ring. One end of the plaster is applied and 
drawn over the umbilicus, the pad in place, and the skin over 
the umbilicus drawn up into small folds. AVhen the adhesive is 
changed, which should be done every four or five days, the 
finger is placed beneath the pad and held until the new strip 
is applied. 

Should the hernia be irreducible, resort should be had to sur- 
gery at once. 



28 THE DISEASES OF CHILDREN 

ATELECTASIS. i 

Definition. This is a condition of the lungs in which all of 
a lobe or a portion of one remains collapsed after birth, the 
lung remaining as in the fetal state. 

Etiology. The condition usually follows an attack of as- 
phyxia neonatorum. If the primary wiping out of the mouth 
and nose is not done, mucus may be aspirated and mechanically 
plug up one of the bronchial tubes, permanently closing it, 
allowing all lung tissue supplied by it to remain collapsed. 

Pathology. The surface of the lung subject of atelectasis 
shows depressions, corresponding to the undilated portion, with 
air in surrounding tissue. These areas do not crepitate on 
pressure and if part of the affected portion is excised it will 
sink in water. Much-dilated bronchioles, areas of compensa- 
tory emphysema, surround the collapsed portion. 

Symptoms. Practically the only diagnostic sign of impor- 
tance is the presence of cyanosis with no heart lesion being 
found. The child does not thrive, is bluish in color, especially 
when crying, and the cry is feeble. Convulsions may rarely 
be seen. The 'physical signs are of little assistance in reaching 
a diagnosis. Owing to the emphysematous areas around the 
atelectasis, no dulness or bronchial breathing can be obtained. 
The respiratory murmur is feeble and slightly harsher than 
normally. 

Treatment. The principal treatment is that of prevention, 
by attempting to cause the child to take deep inspirations imme- 
diately after birth. The methods of artificial respiration men- 
tioned elsewhere should be employed early. 

ICTEEUS. 

Jaundice is present in from one-third to one-half of all new- 
born infants. The depth of the discoloration varies from a 
very slight yellow tinge of the skin and conjunctiva to a deep 
injection. It appears usually about the third day. 



DISEASES AND INJURIES OF THE NEW-BORN 29 

Etiology. Many causes have been suggested. Sepsis causing 
a fatty degeneration of the liver has been named as one of the 
principal causes. Changes in the circulation accident to birth 
has also been named. The cause may be mechanical, as a tumor, 
as in the case of suprarenal hemorrhage (page 24), pressing 
on the gall bladder and ducts. The condition may be hematog- 
enous in character. 

Symptoms. The principal symptom is the yellow discolora- 
tion of the skin, the conjunctiva and of the urine. The child is 
apathetic and dull and does not nurse well. In the moderately 
severe cases the discoloration deepens for a few days and usually 
disappears by the end of the second week. 

Treatment. Saline enemata once or twice daily is of great 
benefit. The ordinary cases usually require no treatment except 
a dose of calomel or castor oil. 

SEPSIS. 

Etiology. This condition is due to an infection of the new- 
born by one or more of the pus-producing organisms, the strep- 
tococcus or the staphylococcus being the most frequent form. 
The most favorable site for entrance of the organism is the 
umbilicus, either before or after the separation of the stump. 
The infecting organism may be carried to this point by the 
capillary action of an infected napkin; hence the necessity for 
an antiseptic dressing to the umbilicus until the navel has 
healed. 

The following portals of entry of the organism may be men- 
tioned: Injuries and abrasions ^ as in a forceps operation, with 
an infection after birth; abrasion of the mucous membrane of 
the mouth; septicemia of the mother during the later weeks of 
pregTiancy; putrefaction of the liquor amnii, with ingestion or 
aspiration of this by the child before and during labor; or a 
violent vaginitis and endocervicitis of the mother before birth 
and infection of child in its progress through the canal ; sup- 
puration of the mammary gland during lactation, and an infec- 



30 THE DISEASES OF CHILDREN 

tioa of a milk duct, with a contamination of the milk, the infec- 
tion being through the gastrointestinal tract; or an infected 
wound following clipping of the frenum linguce in tongue tie 
or following a circumcision. 

Systemic Symptoms. The first evidence of the condition 
usually appears during the first week and may be a failure of 
the child to nurse. If the infection has been at the navel and 
there is peritoneal involvement, or an inflammation of the ves- 
sels under the anterior abdominal wail, there is continuous 
crying, distension of the abdomen and the child lies with legs 
drawn up. The temperature is high but fluctuating; jaundice 
is present when the liver is involved; pulse rapid and small; 
skin hot and dry, and there may be petechial spots develop or 
large ecchymotic areas, frequently they appear on the part which 
is in contact with pillow and bed. 

Prognosis is very grave. 

Treatment. Support and nourishment offer the only possible 
hope of relief. If the child is unable to nurse, rectal feeding 
and gavage must be resorted to, using by the former completely 
peptonized milk, and by gavage, breast milk, if it can be 
obtained. 

Cases. Baby D, born of primiparous mother, after a tedious 
labor, terminated by instrumental delivery, which was easy. 
ISTo abrasions or abnormality noticed. Mother developed sepsis 
during the first week, with temperature to 106° F., on one occa- 
sion. Local focus of infection found in posterior vaginal 
culdesac which had sustained a rent in the mucous membrane 
during the delivery. Cephalhematoma over left parietal devel- 
oped on third day; fever began evening of third day, contin- 
uous and high, often to 104° F. ; hemorrhage from frenum, 
which was clipped at this time ; both ears discharging on tenth 
day; losing weight steadily; gavage; catarrhal enteritis; con- 
vulsions on fourteenth day; jaundice on twentieth day; ecchy- 
moses general, and rigidity of extremities and spine; death 
on twenty-first day. 



DISEASES AND INJURIES OF THE NEW-BORN 31 

Case II. Tedious labor, terminated by forceps delivery, 
child weighing 7% pounds ; normal for first three days ; tem- 
perature of 104° r. on morning of fourth day, which was 
thought to be due to starvation. Artificial feeding reduced 
temperature to 100.6° F., and it was normal the next day. The 
cord dropped off on the fifth day, leaving a moist base. On the 
seventh day the temperature was 102.4° F. ; listless and slow 
about nursing. Pus found in umbilical depression ; pain on 
manipulation of abdominal w^all, and some distension. Con- 
tinuous temperature until its death, three days later, when it 
reached 107° F. Just before its death hands and feet became 
cold and blue, changing to deep purple, the discoloration on the 
lower extremities extending to the hips. • 

INJURIES TO THE NEW-BORN. 

As a result of prolonged labor, pelvic deformities, with instru- 
mental or manual delivery to overcome these conditions, the 
child may sustain fatal injuries, or injuries which may cripple 
it for life. 

High forceps is a capital operation with very serious results 
in a large percentage of cases. Williams, in 119 collected cases 
of high forceps, found a maternal mortality of 40 per cent and 
an infantile mortality of 60 per cent. 

As a result of forceps operation the following injuries may 
be named : Lacerations of the skin by the blades ; injury to eye, 
especially when a fenestrated blade is applied too far up upon 
the head; facial paralysis; depressed cranial bone, or a frac- 
ture of the bones ; cerebral hemorrhage from rupture of vessels 
in the meninges or brain. 

Version may result seriously to a living child. Among the 
most frequent accidents are fractures of the long bones of the 
extremities and the clavicle ; laceration or rupture or hematoma 
of the sternocleidomastoid muscle; fracture and depression of 
the cranial bones ; rupture of vessels in the meninges or of the 



32 THE DISEASES OF CHILDREN 

sinuses in the dura; Erb's paralysis from pressure on the 
brachial plexus of nerves; atelectasis from delayed delivery of 
the after-coming head. 

MASTITIS. 

During the first two weeks after birth the child's breasts fre- 
quently fill up with milk, occurring as frequently in one sex as 
the other. The breasts may become tense and painful to the 
touch, causing restlessness and crying. If friction or pressure 
is used upon them, a breaking down of the gland tissue is apt to 
ensue, or an infection follow which results in a severe inflam- 
mation, with formation of pus. 

Focal Symptoms. Continued enlargement of the breast, red- 
ness of the skin over it, fluctuation, tenderness on manipulation. 

Prognosis. If an abscess does not result, the milk is soon 
absorbed and no trouble results, but if an abscess forms, and 
an incision is necessitated, the function of the gland of a female 
may be impaired in later life. 

Under aseptic precautions, in suspected cases, a hypodermic 
needle may be inserted and the contents aspirated to learn the 
presence or absence of pus. 

STARVATION" TEMPERATURE. 

The accompanying charts indicate the condition which is 
frequently seen during the first few days after birth, the second 
or the third, as a rule, in which there is a rise in temperature, 
and caused to subside from the administration of an artificial 
feeding alone, or which will disappear as soon as the milk 
appears in the mother's breast. It is a phenomenon too infre- 
quently noticed, as the temperature of but few new-born babies 
is taken. 

Symptoms. An apparently perfectly healthy and sound baby 
cries, sucks its fists and tugs at the empty breasts, and is very 
restless ; its skin, mouth and tongue are hot and dry ; and prostra- 



DISEASES AND INJURIES OF THE NEW-BORN 



33 



tion begins promptly. The temperature rises quickly and has 
usually reached its maximum in a few hours. 

Treatment. In the presence of a high fever without other 
definite symptoms the child should be given an artificial feeding, 
if the breasts are not secreting, composed of a weak modified 



--■~.|/kl = 


f_j!i^X4j— 1/ i- ^^^T 


■3 

£ 
C 

£ 

c 

aj 
U. 

K 
D 
H 
< 

Qu 

2 

b 


















107 




















106 
















/5^7r 


^ :^^ y?:- 


















_104 


_ 




1 




[ 














_. _J 




II 




T 




X 




102 J> 


± 


f 


2T 


t 


t i 




III 




M 










T 


w 


± 




t 




iOQ _^ 






/ I 


J 


X 


i: 


I 




I ^ i 


99 v! 


fi ^ 4^ 




^ —^1 ij5 




5:2 SI '^ "^ ^ 








1 2 








■^S 






f «- 









FIG. 6. STARVATION TEMPERATURE. 



milk mixture of a formula approximating the following: Fat 
1., sugar 6., proteid 0.50, i to 1 ounce at a feeding. The 
temperature should be taken again in a few hours to ascertain 
its course, and if on the decline it should be fed regularly until 
the milk comes. If it will not nurse, gavage may be tried 
with excellent results. 



34 THE DISEASES OF CHILDREN 

CEKEBRAL HEMORRHAGE. 

The proneness of new-born infants to hemorrhages, has 
already been referred to. Cerebral hemorrhages may arise from 
the vessels in the brain, meninges or dura, may be very small in 
size or consist of large extravasations. They frequently follow 
a tedious or instrumental delivery and deformed pelvis which 
cause undue intracranial pressure. This complication will be 
referred to in another chapter. 

TETANUS. 

Synonyms. Lockjaw, trismus nascentium. 

Etiology. Tetanus is due to the entrance of the tetanus 
bacillus, into the circulation, its toxins exerting their effect 
particularly upon the central nervous system. The bacillus may 
enter at the umbilicus or an abrasion of the skin carried through 
the medium of unclean hands, dressings, etc. The principal 
habitat of the bacillus is in the neighborhood of stables and 
stable yards, and dust and dirt from this locality may convey 
the infection. 

Pathology. There may not be any characteristic change in the 
tissues at the point of entrance of the bacillus, or a slight in- 
flammatory reaction. The brain and cord may show punctate 
hemorrhages or larger extravasations, as a result of the con- 
vulsions. The internal organs are congested and there are 
serous exudates in the ventricles and cord. 

Symptoms. In a majority of cases the symptoms appear dur- 
ing the first week after birth, though they may occur any time 
before the fourteenth day. It is rare during the third week. 

The first symptom is a spasmodic contraction of the muscles 
of the lower jaw, which very soon becomes fixed, tightly closed. 
It is impossible to push the nipple between the child's gums. 
If liquids are poured into the mouth swallowing is impossible, 
and the first few drops passing the pharynx may cause a reflex 
spasm of the pharyngeal muscles and a general convulsion. The 



DISEASES AND INJURIES OF THE NEW-BORN 35 

child has an anxious, frowning look, between the spasms, and 
a more or less general spasmodic contraction of the facial 
muscles during a convulsion. During a general convulsion the 
respirations are stertorous and between, they are hurried and 
superficial. The sphincters of bladder and rectum are relaxed 
and involuntary passages are usual. As the case progresses 
the periods of rest between the convulsions are shorter, contrac- 
tions begin, the spine becomes contracted, arching backward, the 
opisthotonos being at times extreme, the child resting on head 
and heels. The temperature is usually very high, 104° F. to 
106° F. In the latter period a convulsion may be induced by 
touching the child, especially about the face. Feeding is 
impossible. 

Prognosis is very grave, as nearly all cases die. The younger 
the child the more hopeless the case. Escherich reports 
recoveries. 

Diagnosis. This is usually easy and must be made from 
meningitis and from the paralyses and contractions following 
cerebral hemorrhages of the new-born, and should be easy. 

Treatment. The most favorable results can be had from the 
use of the tetanus antitoxin which, like the diphtheria anti- 
toxin, gives the best results the earlier it is used. Five to ten 
cubic centimetres of the antitoxin may be injected, and repeated 
in from six to eight hours. The subcutaneous method is recom- 
mended, over the injection into the spinal canal, owing to the 
difficulty of performing the latter operation. The influence 
upon the minds of the family of the lumbar puncture is very 
great, and a fatal result of the disease is attributed to the punc- 
ture by the average layman. 

Prophylaxis is the chief treatment, strict cleanliness in tying 
the cord and its care afterward being an absolute essential. 
Upon the appearance of the symptoms, control the convulsions 
if they are severe, by inhalations of chloroform. Give at once 
the following prescription by rectum, using the small bulb 
syringe : 



36 THE DISEASES OF CHILDREN 

R Strontii bromidi gr. v 
Chloralis hydratis gr. ii • 
Aquae distillat gi 

M ft. Clyster. 

This may be repeated in one or two hours for its effect. 
Gavage should be resorted to with tube introduced through the 
nose in those cases in which improvement is noted in the con- 
vulsive stage. 

SCLEREMA. 

Etiology. This is obscure being ascribed as due to sepsis, 
persistent fetal circulation; athrepsia, especially that following 
acute diarrheal diseases and poor nourishment. Two forms 
are described, scleredema or the edematous form, and sclerema 
adiposum or fat sclerema. 

Pathology. In scleredema the changes described are an 
edematous deposit in the skin, cellular tissue, muscles; serum 
in the peritoneal and pleural cavities; inflammatory conditions 
of the intestines and lungs; atelectasis; fatty liver and spleen. 

In the form known as sclerema adiposum, there is a hard- 
ening of the tissues, a drying up of the fat in them, the changes 
in the internal organs being much the same as in the other form. 

Symptoms. In scleredema there is a subnormal temperature, 
with dry, cold skin. The parts fl.rst affected are usually the 
calves of the legs, the thighs, abdominal wall and if severe, 
then the rest of the body. The skin may pit on pressure, or 
in the more severe forms be so tense as not to be influenced by 
pressure. If punctured yellowish serum, rather oily, exudes. 

In favorable cases the skin gradually resumes the normal, 
leaving it wrinkled over the previously affected parts. Desqua- 
mation usually supervenes. 

In sclerema adiposum the legs are also, the first part affected, 
usually symmetrically. It also may involve the whole body, 
except, as a rule, tlie palmar surfaces of the hands and plantar 
surfaces of the feet The skin feels doughy, it is closely adher- 



DISEASES AND INJURIES OF THE NEW-BORN 37 

ent to the underlying tissues. The heart is weak and much 
slower than normalj as are the respirations. The temperature 
is usually lower in this form, 72° F. being recorded as having 
been reached. 

Duration is short in both forms, though it is usually much 
more rapidly fatal in the latter form. 

Prognosis is very grave in both forms, though recovery is 
reported in both. 

Treatment. The first indication is the restoration and main- 
tenance of the body temperature, which can be done by impro- 
vising an incubator. External heat is most important. Stimu- 
lants are necessary, especially whisky and strychnia, 1/200 
grain of the latter, by the mouth or subcutaneously in a portion 
of the body unaffected. Camphor in olive oil may be given 
by hypodermic in very weak heart action with good results. 

External application of cod liver or olive oil, with mild 
massage, is a great help. Gavage may have to be resorted to in 
some cases. 



CHAPTEK IV. 

Growth and Development. 

The average weight for boy babies at birth is about 7^- pounds, 
of girls 7 pounds. But few babies weigh as much as 12 pounds 
at birth. During the first week after birth the child loses in 
weight, frequently as much as a pound, but upon the advent 
of the mother's milk the gain in weight is steady and should 
be not less than 4 ounces a week. Usually at the end of the 
third week it has more than regained its birthweight. 'No 
other single method is of such assistance in determining a 
child's progress as its weight, and a pair of scales should be as 
much a part of a nursery outfit as a baby's bed. The platform 
dial scale upon which has been anchored a basket is a very 
useful one, as it weighs in one-quarter pounds, or the platform, 
arni-balance scale can be used, the baby being laid in the scoop. 
The weighing is best done after a bath when the child has been 
dried ready for dressing. It is thus weighed without clothes 
and with an empty stomach. If the dial scale is used the arrow 
by the set-screw on the top can be made to start at zero after 
the blanket has been placed in the basket; but if the balance 
scale is used the blanket must be accurately weighed and 
deducted from the gross weight. 

As a rule infants which are deprived of normal breast milk 
do not thrive as rapidly as those who are nursed at the breast. 
When a suitable formula of modified milk has been provided the 
gain is then satisfactory. 

The following chart, an average taken from a number of 
published records of investigations, gives the growth of the 
infant from birth through childhood. 



38 



GROWTH AND DEVELOPMENT 



39 



HEAD 
CIRCUM. 



BREADTH 
CHEST. 



Birth / Boys 

\ Girls. 
6mos. J Boys 

\ Girls. 
12 mos. / Boys 

\ Girls. 
18 mos. J Boys. 

\ Girls. 

2 yrs. j Boys 

\ Girls. 

3 yrs. J Boys, 

\ Girls. 

4 yrs. /Boys, 

\ Girls. 

5 yrs. /Boys 

\ Girls. 

6 yrs. /Boys 

\ Girls. 

7 yrs. / Boys 

\ Girls. 

8 yrs. / Boys 

\ Girls. 

9 yrs. / Boys 

\ Girls. 

10 yrs. / Boys 

\ Girls. 

11 yrs. /Boys 

\ Girls, 

12 yrs. / Boys 

\ Girls 

13 yrs. / Boys 

\ Girls. 

14 yrs. /Boys. 

\ Girls. 

15 yrs. /Boys. 

\ Girls. 



7.47 
7.13 
16.0 
15.5 
21.2 
20.4 
22.8 
22.0 
28.4 
27.8 
33.5 
31.5 
36.4 
35.1 
41.4 
40.2 
45.1 
43.6 
49.5 
47.8 
54.5 
52.2 
59.8 
57.4 
66.0 
63.0 
71.5 
69.9 
78.8 
80.0 
86.0 
89.9 
97.2 
99.3 
104.1 
107.5 



20.1 
19.9 
25.4 
25.0 
29.2 
28.7 
30.0 
29.7 
33.1 
32.7 
36.0 
35.6 
38.6 
38.4' 
41.7 
41.3 
44.0 
43.4 
46.1 
45.8 
.48.5 
47.8 
50.0 
49.6 
52.0 
51.7 
53.8 
53.8 
55.6 
56.6 
57.8 
58.6 
60.5 
60.3 
62.9 
61.5 



13.8 
13.3 
16.5 
16.5 
17.9 
17.9 
18.5 
18.0 
19.1 
18.3 
19.3 
19.0 
19.7 
19.5 
20.3 
19.9 
20.0 
19.8 
20.0 
20.0 
20.5 
20.2 
20.6 
21.2 
20.6 
20.5 
20.8 
20.7 
21.0 
20.9 
21.1 
21.5 
21.3 
21.3 
22.2 
22.0 



13.0 
12.4 
16.6 
15.6 
17.9 
18.2 
18.5 
18.2 
19.5 
18.2 
20.1 
19.8 
20.7 
20.5 
21.5 
21.2 
23.2 
22.8 
23.7 
23.3 
24.4 
23.8 
25.1 
24.5 
25.8 
24.7 
27.2 
25.8 
27.5 
26.8 
27.7 
28.5 
28.8 
30.0 
30.5 
31.0 



While it is of great service to the physician in estimating 
the progress of a child, to know its weight from week to week, 
this regular weekly weighing may unnecessarily worry a ner- 
vous mother, and some discretion must be exercised in request- 
ing it. 



40 THE DISEASES OF CHILDREN 

The suggestion of Holt that a record blank or "progress 
report" be printed and given to mothers when dismissed from 
their puerperinm, which are to be filled out and mailed to the 
physician at weekly or bi-weekly intervals, is a most excellent 
one. The following chart, a modification of Holt's, is of great 
service in recording the progress of the child; its weight, gain 
or loss; digestion, disposition, food prescriptions, etc. In the 
card index system it is easily referred to, and a matter of per- 
manent record: 

REPORT ON PROGRESS OF 

Name Date 190 . . 

Weight )b oz. Gain oz. Since last report 

Loss oz. 

Stools avg. in 24 hours Color Mucus 

Curds Watery Loose Thick 

Flatulency or cole? 

Appetite: Is child satisfied? Is any food left? 

Is the child comfotable and good natured? 

How much does he sleep? 

Date of last report? 

I^ F. S. P Cr. % Sk.M M. S 

No feed Interval Dil Aq Aq. C 

Each 5 Total 24 hr. 5 



The child's first years are usually divided as follows, early 
infancy from birth to the twelfth month; infancy until the 
completion of dentition, usually about two and a half years, 
childhood from this time until puberty. 

The measurements of the chest and head are given in Table 
1. It can be noted by reference to the table that at birth the 
head is greater in circumference than the chest; at the third 
year they are about equal, and from this time on the chest is 
larger. 

The new-born infant should have regained its birthweight 
shortly after the end of the first week ; by the end of the second 
week, gained 2 to 4 ounces ; at 16 weeks its birthweight is 
usually doubled, and at one year of age it is usually three times 
its birthweight. 



GROWTH AND DEVELOPMENT 



41 



The most rapid growth of the infant during the first year is 
in its weight. Its increase in length in this period is about 
8 inches, and after this it is at the rate of about 4 inches a year. 

Any serious interference in this ratio, approximately, is an 
evidence of defective nutrition as a rule, and should receive 
prompt and careful attention. Schwartz* has suggested the 



FIG. 7. STEELYARDS FOR INITIAL WEIGHING OF BABY. SLEEVE AT BOTTOM 
CAN BE SHIFTED TO BEGIN WEIGHT AT ZERO. 

following tables for calculating the weight and height at differ- 
ent ages: 

Weight first twelve months. Third to seventh month, add 10 
to the month ; other months add 8 to the month. 

Example: Weight at 4th month? 4 -l- 10 = 14 lbs. 
Weight at 10th month? 10 + 8 = 18 lbs. 



* N. Y. Medical Journal, 



42 THE DISEASES OF CHILDREN 

Weight of a child at any age. Multiply the age of the child, 
plus 1, by 6, and add 10; except for the twelfth, thirteenth 
and fourteenth years add 15, 20 and 25, respectively. 

Example: Weight of child at 4 years? 

4+1=5 5 X 5 = 25 25 + 10 = 35 lbs. 
Weight of child at 15th year? 

15 + 1 = 16 16 X 5 = 80 80 + 20 = 100 lbs. 

Height of child at any age. Up to the sixth year multiply 
the year by 3 and add 26, after the sixth year multiply by 2 
and add 32. 

Example: Height of child at 4 years? 

4 X 3 = 12 12 + 26-38 inches. 

DENTITION. 

The process of eruption of the teeth through the gums is denti- 
tion. A child may be born with a tooth through the gum, but 
these cases are most rare, and the teeth very soon become 
loose and fall out. The first teeth are the temporary, deciduous 
or milk set, and are composed of two central and two lateral 
incisors, two canines and four molars in each jaw. The teeth 
are found in the jaws about the sixth week of intrauterine 
existence. As nutrition proceeds the crown is completed, the 
root hardens and develops, and they are forced outward through 
the gums. 

The eruption of the teeth is a physiological and entirely 
normal process, and should not be looked upon as the bugbear 
of infancy. It is very easy to state that any pathologic condi- 
tion, especially gastrointestinal disturbances, occurring during 
the first five months, are due to the teeth, and not look to the 
diet, for instance, as a cause of the disturbance. 

Unquestioned cases of disturbance of digestion, vomiting or 
mild diarrhea; or mild but persistent cough, are seen during 
the early period of dentition, with more or less prompt relief 
of symptoms when the gum is penetrated by the tooth. Cases in 



GROWTH AND DEVELOPMENT 



43 



which these symptoms are coincident with the eruption of a 
tooth are alm.0Ht without exception subjects of other disorders, 
principally of nutrition. Much delayed dentition is usually 
due to rachitis. There is usually an active development of the 
salivary glands some weeks before a tooth is cut, and there is 




\^^^. ^^ MOLAR /-'S^^:^// 



POSTERIOR. 

MO Lars 

CENTRAL 
r INCISORS: 




FIG. 8. TEMPORARY KisTi PERMANENT TEETH. 



a constant escape of saliva from the mouth during the waking 
hours. The child may be more restless than usual, and bite 
upon everything it can grasp with its hand. 

It is in those cases which show some nervous symptoms and 
restlessness or which present some of the other symptoms enu- 
merated, that the most benefit is had from making an incision 



44 THE DISEASES OF CHILDREN 

through the gums. This does not retard the eruption of the 
teeth through the scar tissue which may form over the tooth, 
but relieves the tension and swelling of the gums and many 
or all of the symptoms. The child is held upon the lap of 
the nurse, who sits facing the operator. The child sits with 
its back to the operator, and with the nurse holding its hands 
its head is lowered between the knees of the operator and there 
held. With one hand holding open the gums and retracting 
the lip, the incision is made directly over the teeth with the 
other. It is generally not ^accessary to lance the gums over 
the molars as they usually erupt one sharp prong at a time 
and without symptoms or difficulty. The first deciduous teeth 
to fall out are the upper central incisors, as a rule, the perma- 
nent teeth very shortly afterward coming in. The first milk 
teeth are lost usually at the end of the sixth year, the 20 occu- 
pying the site of these and are followed by 12 molars. The 
deciduous teeth usually appear as follows: 

Two lower central incisors, six to nine months. 

Four upper incisors, seven to ten months. 

Two lower lateral incisors, 12 to 14 months. 

Two anterior upper molars 1 ^ ^ . - ^ ^^ 

^ . , -. y 12 to 16 months. 

iwo anterior lower molars J 

Two tipper canines (eye teeth) 1 ^g ^^ ^4 months. 

Two lower canines (stomach teeth) J 

Two upper posterior molars \ ^^ ^^ g^ ^^^^^^ 

Two lower posterior molars J 

The permanent teeth usually are cut as follows : 

Four first molars, six years. 

Four central incisors, seven years. 

Four lateral incisors, eight years. 

Four bicuspids, eight and one-half to nine years. 

Four biscuspids, ten years. 

Four canines, 11 years. 

Four second molars, 12 to 13 years. 

Four wisdom teeth, 18 to 25 years. 



GROWTH AND DEVELOPMENT 45 

An attack of acute illness, just at the time of the dentition, 
may seriously impair the life of the tooth. 

Case I. Mother nursing infant of three months developed 
a severe typhoid fever. Baby removed at once and put on mod- 
ified milk. In ten days or two weeks afterward child developed 
a typical attack of typhoid fever, which ran a mild but usual 
course. Very soon after the subsidence of the fever she cut 
her first teeth. She rapidly began to gain in weight, but a 
black line developed on the upper central incisors. This deep- 
ened and finally the teeth broke off through the line, short with 
the gums, and no other teeth have displaced them, though the 
child is now four years of age. 

MENSTRUATION. , 

Menstruation usually begins in this climate between the 
thirteenth and fifteenth years of age. In 174 girls, inmates of 
the Masonic Home, the following were the ages recorded for 
the beginning of menstruation: 

1 1 years ~. 2 

12 years 18 

13 years 47 

14 years 71 

15 years 33 

16 years 3 

174 

It was usual for these children to menstruate once, per- 
haps twice, then miss for several months, and begin again 
and with regularity. Very frequently one month, occasionally 
two months, were skipped in a year, without apparent cause. 
1^0 special season was noted for this to occur. When more 
than three months were missed after regular periods had become 
established, attention was given, and a few weeks tonic treat- 
ment usually resulted in its re-establishment. 



CHAPTEE V. 

Methods of Examination?^. 

Physical diagnosis in pediatrics is our chief diagnostic aid, 
and all of the known methods should be employed; inspection, 
palpation, auscultation, mensuration and percussion, chemical 
analyses of secretions and excretions, and microscopic examina- 
tion of serum, blood, excretions and exudates, etc. The value 
of the information obtained from mother and nurse should 
not be minimized, but one should not be influenced by mislead- 
ing and irrelevant statements. 

A child should always be carefully inspected as it lies, espe- 
cially if asleep ; its position ; color ; respiration, character and 
frequency ; dilatation of the alse nasi ; temperature of hands 
and feet. 

Diplomacy yields best returns in a physician's interview 
with a child. If you once obtain its confidence the rest is easy. 
The child may be nervous, cross and irritable ; will cry when 
touched; it may be almost vicious in its resistance to examina- 
tion. Each child is an individual, and no method of approach 
will suffice in two successive cases. 

Too much emphasis cannot be laid on the importance of care- 
ful history taking and recording the findings in every case. 
This is best done on suitable blanks which can be filled out at 
the bedside, and filed in card index systems. A daily resume 
of symptoms and treatment are recorded and filed with the first 
chart. Previous illness, dentition, food, bowels, and the symp- 
toms and course of present illness are carefully recorded, and 
a daily record blank used afterward in connection with the 
case. A blank used by the author for the first history is shown 
here : 

46 



METHODS OF EXAMINATION 



47 



190. 



.Frd. 
Chg.. 



Name Tot 

Add Paid 

Ser. To Bal. 



Dr. 



Cr. 



Prem 

Born Term Labor j Duration Cond. birth 

]^ Instrument 



Wt. at birth Breast fed 



{Vigorous 
Respir. . . 
Convuls.. 
, Diet since . 



Wt 

Teeth 1st . . 

Crept Walked 

Measles Pertussis Scarlat Diphth . 

Tonsil. Otitis Croup Bronch 



Nervous sys Sleep . 



.Grip 

. . Pneumon 
Adenoids . 




FIG. 9. 1, supra-scapular; 2, inter-scapular; 3, scapular; 

4, INFRA -scapular. 



4S 



THE DISEASES OF CHILDREN 



Note the child as it awakens, whether bright, quiet, peevish 
or crying; size of its pupils, color of skin, etc. A child cries 
for some cause as a rule. Kilmer gives the following 11 causes 
for a child's crying: 

1, because it is hungry; 2, because it is in pain; 3, because 
it is thirsty; 4, because it wants attention; 6, it is sleepy; 6, its 




fig. 10. 1; supra-sternal space; 2, sternal; 3, supra-claviculah; 4, 
clavicular; 5, infra-clavicular; 6, mammary; 7, infra-mammary, 

napkin is wet ; 7, it is tired lying in one position ; 8, it is fright- 
ened; 9, it is exhausted; 10, it is crying from temper; 11, it 
is uncomfortable, clothes wrinkled, etc. It must be remem- 
bered that a normal healthy child does not cry from choice. 



METHODS OF EXAMINATION 49 

Inspection should include a personal view of the napkins, 
especially if there has been any variation from normal in the 
evacuations. 'No description by nurse or mother is adequate 
to convey the real character of an action. 

It should be determined whether the sight of the child is 
normal or impaired, if the pupils are equal, contracted, dilated 
or fixed. The presence of nystagmus, or side to side move- 
ments of the eyeball is noted. If the child is able to be up, 
the character of the gait should be noted. The reflexes also 
should be noted. The chief one is the knee reflex, obtained by 
tapping the tendon below the patella while supporting the 
thigh and allowing the leg to hang naturally. 

Kernig's Sign. The child lying upon its back with thigh 
flexed half way upon the abdomen, the leg cannot be flexed on 
the thigh. 

Babinski's Reflex. With leg extended and slight irritation 
of the plantar surface of the foot the great toe is fully extended. 
This reflex is noted specially in tubercular meningitis, though 
authorities differ as to its value as a diagnostic sign. 

Sach's Sign of Chorea. The child, standing before the exam- 
iner, is asked to repeat a certain sentence, and in the effort to 
do so there is a decided tremor of the hands, which are held in 
those of the examiner. 

The cry of a child is usually characteristic. In cerebral 
affections the cry is shrill and sudden; in affections of the 
larynx it is hoarse, brassy, strident ; with middle ear inflamma- 
tions it is continuous and shrill and accompanied with pulling 
at the ear affected; in colic the child cries loudly and inter- 
mittently, and continuously flexes and extends its legs and 
thighs. 

Temperature. As already stated the temperature of the child 
during the first year is usually between 99° and 99.5° F. An 
infant's temperature should always be taken in the rectum. If 
the mother has a thermometer hers should be used, and if not 
the physician should carry two, one for use in the rectum only. 



50 THE DISEASES OF CHILDREN 

The child may be held upon the nurse's lap lying upon its 
abdomen, legs hanging down. With napkin off; the thermom- 
eter, well anointed, is carefully passed iiito the rectum and 
allowed to remain for two minutes. Half -minute thermometers 
are not reliable. The child may be placed upon its side, on the 
nurse's lap or in bed, with thighs ilexed, but under no circum- 
stances should the thermometer be inserted in the rectum with 
the child lying on its back with legs and thighs flexed, as it 
may raise the hips from the bed and break the thermometer. 

After taking the temperature the thermometer should be care- 
fully washed with soap and water and placed in alcohol for a 
moment. I have had some success with the clean shield rubber 
covering to the thermometer, which is thrown away as soon as 
used. The possibility of transmission of infection in girl babies 
of vulvovaginitis should be borne in mind. Groin or axillary 
temperature in a child are always unreliable. 

I saw a child in consultation, ill with pneumonia, and from 
the extent of the consolidation was surprised at the temperature 
recorded being 102.5° F., it having been taken in the axilla. 
I requested it taken in the rectum and found it 105° F., which 
was more in keeping with the other symptoms. 

Another case recently occurred in which a rectal tempera- 
ture in a suspected typhoid was recorded as 97° F., with every 
indication of fever. A change of thermometers showed it to 
be 102° F. Examination of the first one revealed the fact that 
it was not self-registering, the mercury falling into the bulb as 
soon as it was removed from the rectum. These things must 
be borne in mind. 

The throat of every sick child should be carefully inspected. 
The child is held facing a strong natural or artificial light, 
with back to the right shoulder of the nurse, who holds the 
child's hands. The examiner with his left hand holds the head 
and with the right depresses the tongue Avith spoon or tongue 
depressor, and a quick view of the fauces, tonsils and uvula is 
obtained. Young infants are usually not frightened by a head 



METHODS OF EXAMINATION 



51 



mirror, tliougli older children may be unless its use is explained 
to them. 

The importance of this examination cannot be too forcibly 
emphasized, as frequently severe attacks of diphtheria may 
develop without any pain or discomfort or inability to swallow 
being complained of. The use of the wooden tongue depressor, 




11. POSITION ASSUMED FOR INSPECTION OF THROAT; NURSE HOLDING 
HANDS AND LEGS. 



which is thrown away after using, is recommended instead of 
metal tongue depressor or spoon. 

The mucous membrane of the mouth, cheeks and lips should 
be inspected for the presence of the buccal eruption of measles 
(Koplik), which is referred to under another chapter, or for 
the presence of ulcers or deposit of thrush or sprue. 



52 



THE DISEASES OF CHILDREN 



The tongue is inspected and its general condition noted ; 
whether the frennm linguse is short and inhibits the range of 
motion ; if it is dry, coated, flabby, and shows the imprint of 
the teeth ; if it presents the characteristics of the strawberry- 
tongue of scarlet fever, or if ulcers are present at any place on 
its surface. 




FIG. 12. TONGUE DEPRESSOR WITH REMOVABLE WOODEN DEPRESSORS. 



Examination of the middle ear is a procedure too frequently 
neglected by the practitioner. Many cases of unexplained fever 
of some duration in children can be cleared up by an inspection 
of the drum membrane. A bulging congested drum means 




EAR SPECULA. 



middle ear trouble. An inspection is made through a small 
size ear speculum (the lobe of the ear being drawn down, as 
suggested by Dr. Jas. F. McKernon of 'New York), by reflected 
light from a head mirror. The child is held in the nurse's lap, 



METHODS OF EXAMINATION 53 

the unaffected side against the breast of the nurse, her hand 
supporting the head. With the light behind the nurse's head, 
an unobstructed view of the canal and the drum can be had. 

The nose should receive attention, as much may be found 
here to cause discomfort if not symptoms. The child is sup- 
ported much as for a throat examination, with chin elevated 
and a good view of the entrance to each nostril obtained. 

Hypertrophied turbinates frequently encroach on the space 
of the nostril, especially when there is an acute coryza. Con- 
cretions of dried discharge also may have to be removed before 
a view can be had. Anointing with vaseline, by means of a 
cotton-protected swab, gives great comfort in these cases. The 
habit of older children of putting foreign bodies, as shoe but- 
tons, beans, etc., in the nostril and ears should be borne in mind. 
I recently removed a foot of a small china doll from the nose 
of a two-year-old child, experiencing some difficulty in getting 
a firm hold of it with a forceps. 

The slcin should be carefully examined for eruptions, and at 
this time the child's clothes must be entirely removed. En- 
largement of the superficial glands must be looked for, axillary, 
postcervical, submaxillary, epitrochlear and inguinal. 

Palpation. Palpation of the chest wdth warmed hand on 
first the anterior surface then the posterior should be done to 
ascertain presence or absence of ronchi or rattles. 

The ribs should be examined for beading and the epiphyses 
of the long bones for enlargement. The lower abdomen and 
inguinal region should be palpated for hernia, and the scrotum 
for hydrocele, hernia or undescended testicle. 

The frequency of the heart beat can be determined by palpa- 
tion of the apex beat, or feeling the pulse at the wrist, temple, 
groin or ankle. Its character can best be learned by palpation 
of. the radial artery at the wrist. The frequency of the heart 
can also be determined by auscultation over the apex, or inspec- 
tion of the precordial region. 

The abdomen should be carefully palpated to ascertain the 



54 THE DISEASES OF CHILDREN 

presence of tumors or marked glandular enlargement; the 
muscle guard over an inflamed appendix; an enlarged liver 
or spleen. An enlarged liver may be determined also by per- 
cussion, but an enlarged spleen only by palpation. The pres- 
ence of underlying distended intestine prevents percussion from 
being of value in investigating the spleen. 

Rectal palpation is of great service in diagnosticating sus- 
pected cases of intussusception. This should be done with the 
utmost gentleness. Inspection of the rectum for fissure should 
be made whenever a child cries with the passage of his move- 
ments, especially if there is any blood with the action. 

With patient on a table, lying on its face, the spine is in- 
spected and palpated. If local bone changes (Pott's disease) 
are suspected the examination includes an effort to locate 
rigidity. 

Auscultation of the chest is the most important aid to diag- 
nosis of diseases located there. 

A complete auscultation of the chest cannot be made without 
the aid of a stethoscope, either the binaural, bell stethoscope 




FIG. 14. BOWLES STETHOSCOPE WITH SMALL CHEST PIECE. 

with small chest piece, or the Bowles stethoscope with the small 
chest piece. The child should be held so high that the examiner 
does not have to bend over, thus compressing his abdominal 
vessels, and causing a flushing of the face and ringing in the 
ears. It may either be held on the nurse's shoulder for exam- 
ination of the back, or face down upon the nurse's lap. Auscul- 
tation with the ear of the axillary region in a child is impossible. 
I have seen one case of deep-seated pneumonia with only one 
spot the size of a 25-cent piece showing bronchial breathing, and 
this was located in the extreme upper portion of the axilla 



METHODS OF EXAMINATION 



55 



where the ear could not possibly have been placed. Then, too, 
the ear covers too much space and it is impossible to localize 
a small area of consolidation. 

As the auscultation is proceeded with comparison should be 
made of the two sides at exactly corresponding points. It should 
be remembered that the child's chest wall is thin and is a better 
conductor of sound than an adult's, the bronchial tissue is 




FIG. 15. 1, AXILLARY REGION; 2, INFRA-AXILLARY REGION. 

greater in proportion than the vesicular, hence the respiratory 
sounds, especially expiration, will be much higher-pitched than 
the adult's. In fact, when listening to a child's lungs, it is well 
to forget the sounds in an adult's chest, they are so different. 
The sound over the upper third of the sternum and along the 
second and third interspaces is quite bronchial in character, 



56 



THE DISEASES OF CHILDREN 



especially on the right side^ because of the larger size of the 
right primary bronchus and its angle at this point, allowing a 
larger volume of air to enter this side. This is true also over 
the interscapular spaces. 




FIG. 16. POSITION FOR AUSCULTATION OF BACK. 



Percussion. Percussion over the chest may be performed with 
the finger as the pleximeter, and a percussion hammer, or with 
the index and second fingers of one hand as the hammer. The 
pleximeter finger should be placed the same on each side, if 
on the second rib on one side it must be similarly placed on 
the other, to obtain a comparison of sound. In percussing over 
the posterior wall, the presence of the liver on the right side 
under the ninth rib must be remembered, and not mistake the 



METHODS OF EXAMINATION 57 

absence of resonance for consolidation or exudate in the pleural 
cavity. The area of dulness over the heart can be easily deter- 
mined by superficial percussion. On deep percussion in this 
area^ there is apt to be a transmitted resonance from underlying 
lung tissue. 

^iiiiiiiiiiir"i ^i [|Q 

FIG. 17. Stanton's percussion hammer. 

Mensuration. This is a valuable aid in diagnosis. A tape 
on a spring in a case which will roll up on pressing a release 
button is most satisfactory. The metal tape bearing the metric 
measurements on one side and English on the other is a very 
serviceable one^ but the greatest objection is the chill which it 
causes when brought in contact with the skin. 

In hydro thorax or pneumohydrothorax, the tape is of the 
greatest service in estimating the amount of effusion. In 
enlargement of the joints it is an assistance, also in ascertaining 
the presence or absence of shortening of the lower extremities. 
In making this measurement the comparison of the two sides 
is taken from the anterior superior spinous processes of the 
ilium and the internal malleolus of the tibia. The measure- 
ment from the umbilicus as the fixed point is relative only. 

A useful tape in comparing the expansion of the two sides 
is made by sewing together two tapes at 1 inch end, this junc- 
tion being held upon the spine as deep inspiration is taken. 

The comparative measurement of the head and chest is of 
value also. The circumference of the head is taken around 
the middle of the forehead and over the parietal bosses, and 
around the nipples for the chest. 



CHAPTEE VI. 

Theeapeutics of Infancy and Childhood. 

There should always be a clear indication for medication in 
children, and no remedy employed without the indication is 
present. Children respond readily to therapeutic measures, and 
this should be borne in mind in dosage. 

Young's method of figuring the dose of a given medicine for 
a child is as follows : Add 12 to the age of the child and divide 
the age by this sum, which will give the proportionate quantity 
of the adult dose. 

Example: If the age of the child is two years: 

2 + 12 = 14 2 (the age of the child 4- 14 = 2-14 or 
\ the adult dose. 



Cowling's Rule. Divide the age of the child at its following 
birthday by 24, the result being the proportionate adult dose 
for the child. 

Example: If the child is two years old, 2 -^ 24 = 2-24 or 1-12 the 
adult dose. 

ISTo medicine should be given a child under three years of 
age, in 'pill form, owing to the possibility of the pill being 
aspirated into a bronchus. It is a good plan to teach children 
to swallow pills by making a mass of bread, as much that is 
disagreeable to the taste can be administered in this form. 

Powders are not well taken by children, and should either be 
dissolved or suspended in a watery solution or in an emulsion. 
If a powder is given dry it is very apt to gag the child as it 
gets in the mouth or some of it may be aspirated into the larynx 
and cause violent coughing. 

Enemata are as a rule well borne. If nutrient, they should 
be given half high and never in very large quantities. Two 

58 



THERAPEUTICS OF INFANCY AND CHILDHOOD 59 

ounces is as mucli as will be taken care of as a rule, and they 
should not be repeated too frequently. Owing to the loose 
mesentery of the sigmoid flexure, and the relative greater length 
of this portion of the bowel a child requires a larger quantity 
of fluid for purposes of evacuation than is usually given. The 
pressure of the fluid in the bag should not be very great, the 
bag not being held more than 3 feet above the patient. The 
bulb or Davidson syringe should never be used on an infant. 
It is impossible to keep this kind of syringe clean, and one can- 
not gauge the amount of pressure exerted on the resistent bowel. 
The use of the high, copious enema for the purpose of reducing 
an intussusception is a remedy which if used at all should be 
used with the greatest caution. 




FIG. 18. SOFT RUBBER BULB SYRINGE. 

Suppositories are efficient and, if not too large or too often 
repeated, can be used as a means of medication or to evacuate 
the bowel. For the latter purpose the long glycerine pencil 
is very practical and very efficient. In writing a prescription 
for a suppository directions should always be given that they 
be small. 

Inhalation. In older children much good can be accom- 
plished by a croup kettle or steam atomizer. The small steam 
atomizer is placed at the side of the bed and a sheet so arranged 
as to cover three sides of the bed; in this way the child con- 
stantly breathes moist air, which can be either with or without 



6U 



THE DISEASES OF CHILDREN 



a medicanient. Benzoin is a very soothing remedy and may 
be added to the water in the atomizer. 

In older children the inhalation can be given by making a 
paper cornucopia to the top of a pitcher or Mason jar holding 
hot water. The face is held over this and deep inhalations 
taken of the plain or medicated vapor. 

In spasmodic croup, or true croup (diphtheria), especially 
when a tube is worn in the latter, the moist air is of the great- 
est help. 




FIG. 19. STEAM ATOMIZER. 



Gargles may be employed in older children when indicated. 
A child has to be taught to gargle, as a rule, and usually in a few 
attempts will succeed. 

Hypodermoclysis. In certain conditions where there is a 
septic condition or a marked collapse from any acute or wasting 
disease, this method of treatment yields excellent results. 
Enterocylsis, referred to elsewhere, especially by the continu- 
ous method, is of great service also. 

In hypodermoclysis, a normal salt solution, approximately 
one teaspoonful of salt to a pint of distilled or filtered water, 
is injected into the cellular tissue of the skin. These injections 
should be at a temperature of 100° F., and in quantities not 



THERAPEUTICS OF INFANCY AND CHILDHOOD 1 

to exceed 40 to 50 cc. at a time. Careful sterilization of the 
needles and apparatus, and of the skin should be obtained. It 
can be given with a fountain syringe, or a large antitoxin 
syringe, such as were formerly used for the injection of diph- 
theria antitoxin. 

Calomel Vapor Inhalations. A tent is made in the same way 
as for steam medication, the steam started and 10 grains of 
calomel sublimed in the tent, its fumes being added to the steam. 
The calomel can be heated in a spoon held over a candle or 
alcohol lamp, or in specially-devised sublimers. This form of 
treatment was used formerly more frequently than of late, espe- 
cially in diphtheria affecting the larynx. 

Medicinal Antipyretics should be used in children with great 
caution, this being specially true of the coal-tar products, anti- 
pyrine, acetanilid, antifebrine and phenacetine. Children bear 
hydrotherapeutic measures very well indeed, and these should 
be used to the exclusion of the medicinal antipyretics in all 
forms of hyperpyrexia. If it is necessary to give them, the use 
of caffeine at the same time is advocated. 

Stimulants are well borne as a rule, alcohol in some form; 
strychnia, nitroglycerine, sparteine, digitalis, all being well 
borne by children. Alcohol in certain conditions is the best 
form of stimulant, as in the crisis of lobar pneumonia, late in 
typhoid fever, diphtheria and the exanthemata. It should be 
well diluted, at least 1 to 6 or 8 parts of water, and if whisky 
is used, a good straight, bottled in bond, article should be in- 
sisted upon. Do not begin the use of alcohol in the beginning 
of any illness and not at all until there is a positive indication 
for it. It may, under conditions where the stomach will not 
retain it, be given by the rectum, but in larger quantities and 
the same dilution. Brandy will often be tolerated when 
whisky will not. 

Camphor is a diffusible stimulant, and may be used by hypo- 
dermic injection in olive oil, ^ or 1 grain in 20 drops of olive 
oil. 



62 THE DISEASES OF CHILDREN 

Anodynes. Children are peculiarly susceptible to anodynes, 
and they should be given with great caution. Opium, in any 
form, should never be given mixed with other drugs in a pre- 
scription. It can be given at the same time, but added to the 
mixture at the time of giving. In this way a relatively large 
dose can be given as a rule. Chloral is also well borne and can 
be given by the stomach or bowel. 

Counter Irritants are easy of application owing to the deli- 
cateness of the child's skin. Mustard, turpentine, chloroform, 
in the form of sinapisms or liniments ; iodine must be used with 
caution to guard against blistering. Blisters are easily raised 
when desired by cantharides in form of plaster or collodion. 

Weak mustard plasters in my hands have been of greater 
service than a strong mixture. One part of mustard to 6 or 
8 parts of flour is very efficient and soothing. In bronchitis, 
bronchopneumonia, pleurisy and intercostal neuralgia the appli- 
cation of a mustard plaster is of the greatest efficiency. 

The Bath. The bath is a most important and useful means 
of combating certain symptoms in children. It is the most 
important antipyretic measure, and if children are early taught 
to enjoy the bath and are not frightened by being plunged into 
too cold water, it will always be a pleasure to them to be bathed. 

A bath thermometer should be a part of the equipment of 
every nursery, and the temperature of the water accurately 
taken. Do not use the child as thermometer, ^'if the water is 
too cold the skin turning blue, and if too hot the skin turning- 
red." ^Vhen used as an antipyretic the water should at first 
be about 95° F. and cooled to 75° F. or 80° F., according to 
its effect on the child. The tub should be large enough to allow 
the child to recline, its head supported by the arm of the mother 
or nurse. If the bath is given in a porcelain tub, a bath towel 
is laid on the bottom so the child will not slip about, or the 
cold tub be disagreeable. Cold water or ice water is added at 
one end of the tub, away from the child, and the water 
thoroughly mixed. The child is gently rubbed, legs and arms. 



THERAPEUTICS OF INFANCY AND CHILDHOOD 



63 



back and chest, during the entire time it is in the water. If 
the teeth begin to chatter and the child to shiver, the bath 
should not be prolonged. 'No hard and fast rule can be given 
as to the duration of the bath, as children react so differently. 
An average duration of ten minutes is the proper length of a 
bath for its antipyretic effect. 

Should a child object to the bath from fright, it can be low- 
ered into the water in a sheet stretched across the tub, and the 
water gradually covering the body. 





'^^^•^ 



FIG. 20. FOLDING RUBBER BATH TUB. 



The rectal temperature should be taken just before the bath 
and 30 minutes afterward. If the child still feels hot when 
it is removed from the water and is dried, increased radiation 
can be accomplished by rubbing with a weak solution of alcohol, 
1 tablespoonful to 6 ounces of water, allowing this to evaporate, 
the sponging being continued for ^ve or ten minutes. 

A preliminary bath before the physician arrives in the pres- 
ence of temperature above 103° F. is always indicated, and 
mothers should be told to do this without further instructions. 

In older children the regular bath should be a delight instead 
of a bugbear. In those who are susceptible to ^ 'colds," a cool 



64 THE DISEASES OF CHILDREN 

bath, or the cool sponge, of the chest and back following a warm 
bath, this followed by a brisk rub, is of the greatest benefit. 
With some children the spinal douche of cold water can be 
employed, but not very frequently. Some children prefer a cool 
bath, always. I have two boys under my observation, aged 4 
years and 18 months, who have a daily bath in water between 
55° F. and 60° F., and object to a temperature even as high 
as 70° F. 

In hot weather, a second bath at night before retiring gives 
great comfort and insures a good night's rest. 

Bran Bath. Two teacup fuls of bran, to enough water in the 
tub to cover the child's legs when sitting in the water, is of 
great service in itching, irritated, skin, due to urticaria and 
prickly heat. The water is splashed on the body and the skin 
is not rubbed. The temperature of the water should be below 
80° F. On removal from the tub the skin is quickly dried with 
soft towels, without friction, and the surface freely powdered 
with talcum. 

Soda Bath. In urticaria, especially, a general soda bath gives 
much comfort, or a basin bath may be used, the solution being 
^'sopped" on with soft gauze or washcloth. If a general bath is 
given use a half teacupful of the bicarbonate of soda to the 
quantity of water used for the bran bath, or a tablespoonful of 
the soda to a pint of water for the basin bath. This is allowed 
to dry on the skin naturally. 

Mustard Bath. For pulmonary affections the mustard bath 
is of the greatest service. It can be used with benefit also with 
children in convulsions, or very nervous and irritable ones. Two 
heaping tablespoonfuls of Coleman's powdered mustard are dis- 
solved in the usual quantity of water, through a cloth or gauze, 
in order to prevent its floating on the surface, and sticking to 
the sides of the tub. Care should be exercised to prevent the 
child rubbing its eyes with its hands, wet with the mustard 
water. The mustard bath is given at a temperature of from 
95° F. to 100° F., and can be cooled to 85° F. just before 



THERAPEUTICS OF INFANCY AND CHILDHOOD 65 

child is removed. The child is rubbed vigorously between 
blankets and put in bed at once after being dried. 

Brine Bath. In feeble and poorly-nourished children the salt 
or brine bath can be used with benefit, as it acts as a tonic and, 
as a rule, an excellent reaction is obtained. Ordinary salt, or 
if it can be obtained, sea-salt, can be used, one tablespoonful to 
the gallon of water. A basin bath with soap and water can first 
be given, and the child then put in the salt water, the skin being 
rubbed constantly for the five or ten minutes it is kept in the 
water. The reaction from this bath is usually greater than 
from any other form. 

Wet Cool Pack. As an antipyretic measure this is probably 
the best, and one which is infrequently used by the profession 
as a rule. It can be used Avith a child at any age, and may be 
continued for long periods at a time, 10, 12, or as in a case 
reported by Kerley, for 72 hours. The bed is protected by a 
rubber sheet, which is covered with a draw sheet. The child 
is then stripped, its legs being covered by a blanket. A large 
bath towel is used in preference to a sheet. This envelopes the 
child's chest, and is pinned loosely enough to go over the shoul- 
ders, like a pin blanket in the baby, leaving the arms free and 
extending down as far as the middle of the thighs. With bath 
thermometer in the basin of water at the bedside, the tempera- 
ture of the water is carefully watched. The rectal temperature 
of the child is taken, and at half -hour intervals it is taken in 
order to learn the rapidity of the fall. The pack is first put 
on dry. 

The towel is wet thoroughly with water at 90° F. or 95° F. 
in order not to shock the child, the water being put on the towel 
from a piece of gauze which is squeezed on it, the child turned 
in order to have the back wet. In five or ten minutes the water 
is cooled 5°, and the towel again wet in the same way. A 
child with a temperature of 105° F. quickly dries the towel. 
It is the aim to keep it wet constantly. Each time the towel is 
wet the water is cooled until it reaches 70° F. Heat to the 



66 THE DISEASES OF CHILDREN 

feet and cold to the head is a great assistance. An ice bag may 
be laid against the head or cold cloths applied to the forehead 
and vertex. The pack is removed when the temperature is 
reduced to 102° F. 

This treatment is indicated in all forms of pyrexia, from 
whatever cause. Pneumonia, the exanthemata, typhoid fever, 
etc. The presence of a rash is no contraindication, though some 
difficulty may be experienced in some families to convince 
anxious mother and friends that it will not '^drive in the rash.'' 

Mustard Plaster. If properly applied, a mustard plaster is 
of the greatest benefit in certain conditions of the respiratory 
tract, and where counter irritation for any reason is desired. 
The plaster made at home is more effective and less disagreeable 
than the mustard leaves on the market, if the skin is delicate 
and irritable, 1 part of the mustard to 8 or 10 parts of flour 
will be found very serviceable. The mustard flour and the wheat 
flour are made into a thick paste with cold water and spread 
between two thin pieces of cloth, warmed before the fire and 
placed upon the skin. The plaster is allowed to remain on the 
skin until it is reddened, which can be ascertained by lifting up 
the corner of the plaster. After removal the skin is greaserl 
with vaseline, and when the skin has resumed the normal hue 
the plaster can be renewed, a fresh one being made each time. 

Irrigation of the Nose. The child is placed on the nurse's 
lap or on the bed, lying upon its side, its head slightly lower 
than its body. The child can be held upright, sitting in the 
nurse's lap, its head bent slightly forward over a basin. With 
either a fountain syringe or glass syringe, with a rubber tip, 
the solution, warmed to 90° F., is put into the upper nostril 
and allowed to -run out of the lower nares. The child may have 
to be wrapped in a sheet to confine its arms and legs, if it resists 
the operation very much. 

Stomach Washing.* Epstein of Prague, in 1880, recom- 
mended washing the stomach in certain diseases of the gastro- 

* "Stomach Washing in Infants," Tuley, Medical News, July 1, 1893. 



THERAPEUTICS OF INFAXCY AND CHILDHOOD 67 

intestinal tract. Dr. A. Seibert of New York, in 1888, advo- 
cated its use, and since then lavage has been extensively used. 

The apparatus nsed is a Xo 13, American scale, soft rubber 
catheter, not too flexible, about 12 inches in length. This is 
attached to a piece of rubber tubing 2 feet long, with a short 
piece of glass tubing between. A glass or hard-rubber fimnel 
of 2 or 3 ounces capacity is attached to the free end of the 
rubber tubing. 

Plain lukewarm water previously boiled is the only fluid 
which should be used, and as a rule 1 pint is all that is necessary. 

The child is seated upright in the nurse's lap, head against 
her right shoulder. A rubber apron is pinned around the child's 
neck, its lower end, long enough to reach to the floor, in a basin 
or bucket, in front of the nurse's feet. The child's hands are 
held by one of the nurse's hands, its legs by the other. The 
child's tongue is depressed by the left forefinger, and taking 
advantage of the gagging the tube is rapidly pushed down the 
esophagus to the stomach. The tube is wet before being intro- 
duced and no lubrication is needed. 

Some gas may be in the stomach and fill the tube, which will 
obstruct the inflow of the first water poured in the funnel, or 
which is less usual, a curd or bit of mucus may clog the eye 
of the catheter for a few moments. Filling the funnel and 
elevating it to the fullest extent usually causes the water to 
flow in. Through the glass tubing the flow of the water can 
be seen. 

Over-distending the stomach with water causes the child to 
vomit alongside the tube, and frequently thick leathery curds 
are ejected which could not have readily been disintegrated. 

The water is siphoned out as soon as a proper amount has 
been allowed to run in and the process repeated until the wash 
water returns clear. 

In removing the tube it should be grasped firmly in order 
to prevent a few drops falling into the larynx as the tip of the 
catheter passes over the epiglottis. 



6S 



THE DISEASES OF CHILDREN 



After the washing, the stomach should be kept entirely at 
rest, and only the easiest digested food administered. Epstein 
suggested the administration of egg albumen water for 24 hours 
after a stomach washing. 

Irrigation of the Colon. This is a measure frequently abused 
and improperly applied, yet one which is of great benefit Avhen 
properly used. It has been suggested as an antipyretic measure, 
but this should be done with great caution. The indications 
for colon irrigation are referred to elsewhere. 




APPARATUS FOR STOMACH WASHING. 



A 'No. 14, American scale, soft rubber, velvet-eye catheter, 
or a No. 17, American scale, rectal tube with opening in the 
end, is attached to the small tip of a 2 quart fountain syringe. 
The solution and its temperature should be determined by the 
indications to be met. The syringe is held not more than 3 
feet above the patient, and the first of the water in the tube 
allowed to escape so it will run in an even temperature. 



THERAPEUTICS OF INFANCY AND CHILDHOOD 69 

The child is held either on the nurse's lap, which is protected 
by a rubber sheet, or on a bed, close to the edge, on its back 
or left side with hips elevated, and clothes drawn well up under 
its shoulders. A napkin can be pinned loosely around its waist 
and allowed to hang loose over the rubber sheet. A receptacle 
of some kind is placed under the rubber sheet to catch the 
return ^ater. 

The tube or catheter is anointed thoroughly with vaseline, and 
also the anus, as this will make it much easier to introduce the 
tube. After the tube has been inserted 1 or 2 inches the com- 
pression is removed from the tube, and as the water flows in 
it dilates the colon ahead of the tube, making its insertion easy 
as a rule. If straining occurs, the tube is compressed for a 
moment until the spasmodic condition is ' relieved. If a too 
flexible tube is used, as the tip nieets a fold of bowel, it is apt 
to be bent on itself and forced out at the anus during straining. 

The continuous irrigation already referred to is a measure 
of the greatest benefit in conditions such as sepsis, and failure 
of elimination by the kidney. The hips are slightly elevated 
and a medium-size catheter is introduced half way into the 
bowel. The bag is elevated not more than 12 inches above the 
hips, and enough compression used on the tube to cause the 
water to escape in drops, at a rate so that an average of a pint 
will escape an hour. The temperature of the water is kept at 
100° F. by the addition of hot water from time to time as it 
cools. 

Collection of Urine for Examination. Unfortunately the chem- 
ical examination of the urine of children is very often neglected, 
or even entirely omitted by the average practitioner, and prob- 
ably no other method of diagnosis is of greater importance to 
the clinician. In very young babies it is often a very difiicult 
thing to obtain a specimen, especially girl babies, and a most 
useful device has been suggested by Dr. Chapin,"^' which he 
describes as follows: 

* American Pediatric Society. (Archives of Pediatrics, May, 1906). 



70 THE DISEASES OF CHILDREN 

It consists of a circular opening ending in a funnel that fits in a collecting ves- 
sel. Two sizes have been found necessary, small and large, designated respect- 
ively as No. 1 and No. 2, for infants under and over one year. The urinal is 
fixed in place by putting the large opening around the vulva in the female, and 
over the parts in the male, with the funnel pointed downward. Tapes are put 
through the openings in the arms and fixed by tying around the abdomen and 
both groins. To fix more firmly in place, strips of adhesive plaster may be 
pasted over the arms. The end of the funnel is placed in a collecting bottle 
which is kept in position by the diaper. If the baby is very restless, a cork may 
be put in the end of the funnel and the bottle dispensed with, as enough will 
often be thus collected for examination. 

If the child is too ill to be held over a vessel at intervals, if 
a rubber napkin is put on with a small pledget of cotton at 
the nates, some urine will soon be caught, enough for a chem- 
ical and microscopical test. It should be borne in mind that 
any powder used about the vulva may contaminate the urine. 

As an example may be mentioned the case of pyelitis referred 
to elsewhere. The urine from this patient was submitted to an 
expert clinical pathologist who found pus and albumen in the 
urine and also an object under the microscope resembling the 
egg of an intestinal parasite. It was finally remembered that 
lycopodium was used with talcum powder with this child, and 
these objects were the seed pods of the lycopodium. 

Inunction. The skin can be used for introducing medicines 
into the system, though it is a very uncertain method. In 
athreptic and marasmic children some absorption of fat can be 
obtained by inimction, and by enveloping the child in cotton 
soaked with oil, mercury can be introduced through the skin 
by rubbing the ointment into the flexures, using these alternately. 



CHAPTEE VII. 

In"fant Feediis^g. 

Breast Feeding, 'E'o substitute has ever been found for nor- 
mal inoiber's milk for the nourisbmeiit of the infant. The 
infant should be put to the breast as soon as the mother has 
had a rest from her labor^ as the colostrum, present in the 
breast before labor, is essential for its purgative effect on the 
child. During the first 24 hours the child should be nursed 
every six hours ; during the second 24 hours, every four hours ; 
during the third 24 hours, every three hours ; during the fourth 
24 hours, every two hours. The milk usually comes the even- 
ing of the second or the morning of the third day, after which 
time the nursing should be every two hours. If nursed every 
two hours during the first three days the tugging and pulling 
on a flabby, empty breast results in an erosion or fissured nipple. 

A cracked, fissured or eroded nipple is a most painful and 
distressing condition, as well as a dangerous one from the 
possibility of an infection of the breast occurring through this 
open wound. A fissured or eroded nipple should not be nursed 



FIG. 22. GLASS NIPPLE SHIELD. 



from directly, but protected by a nipple shield. The glass 
shield with rubber nipple and guard is the most serviceable. 
Immediately after each nursing the nipple should be painted 

71 



72 



THE DISEASES OF CHILDREN 



with a solution of nitrate of silver, 20 grains to the ounce of 
water, care being taken to limit the application directly to the 
affected part. This forms a pellicle from the coagulated albumen 
of the serum, and allows granulation to occur beneath it. The 
nipple is then covered with a piece of sterile gauze or soft linen. 

After the milk comes, the nursing should be by schedule, 
every two hours during the day and every three hours at night : 
From 6 a. m. to 10 p. m. every two hours, and one or two 
nursings at night. Under no conditions should a baby be 
allowed to sleep with its mother; the danger of over-laying is 
great, as is the danger of the child nursing most of the night. 
This always results seriously to the child's digestion. 

Schedule for nursing a breast-fed baby: 



AGE. 


INTERVAL DAY. 


NUMBER NIGHT 
NURSINGS. 


NUMBER OF 
NURSINGS 24 HR. 


First three days 


4 to 6 
2 

2i 
3 

3 


1 

2 

1 

1 




4 to 6 


Until end of first month 

Second and third months . . . 
Fourth and fifth months .... 
Sixth to twelfth months .... 


10 

" 8 
7 
6 



The child should nurse from one breast at each nursing, 
alternately, and should be satisfied in from 10 to 15 minutes. 
If it must be nursed from both breasts each time, and is unsat- 
isfied when the nursing is finished, the quantity is inadequate 
for its needs. By regularity being established early both the 
baby is trained to good habits, and the breasts to secrete at 
regular intervals. 

The nipples should be washed before and after nursing with 
a solution of boracic acid, and the child's mouth thoroughly 
cleansed before and after the nursing with the same solution. 

It must be a rule to give water to a nursing baby between 
feedings. Before the milk comes, in order to prevent a too 
rapid loss of w^eight, there should be given at regular intervals 
a weak solution of sugar of milk, 1 per cent, or even plain 
sterile water. 



INFANT FEEDING 73 

There are but few contraindications to maternal nursing. A 
severely inverted nipple makes it impossible for the child to 
nurse. IsTursing should not be allowed in mothers suffering 
from tuberculosis in any form ; malignant disease ; diphtheria ; 
rheumatism or chorea; acute contagious diseases and pneu- 
monia; erysipelas; albuminuria; typhoid fever, as the typhoid 
bacillus is excreted in the breast milk; the acute exanthemata; 
pregnancy occurring during lactation ; epilepsy or nephritis, 
or if the mother has suffered from puerperal hemorrhage, neph- 
ritis, eclampsia or infection. 

Nursing Mother. A nursing mother should lead a perfectly 
normal, healthy life. Her diet should be generous and varied. 
There are practically no articles of diet which, if they .agree 
with the mother, will cause the milk to disagree with the child. 

During the first three days of the puerperium the diet should 
be light and easily digested. The following sample diet list 
for the first few days will generally yield good results: 

First day (after labor): 

Breakfast — Cup of tea, or cocoa; piece of dry or buttered toast. 
Lunch — Beef, chicken or mutton broth; toast or wafer. 
Supper — Glass of milk, or cup of tea. 

Second day: 

Breakfast — Cereal and cream with cocoa or tea. 

Lunch — Soft-boiled egg, rice and cream. 

Supper — Milk toast, tea or milk. 
Third day: 

Breakfast — Soft boiled egg, cereal, coffee or milk. 

Lunch — Baked potato, gelatin jelly and cream, and milk. 

Supper — Baked apple and cream or milk toast. 
Fourth day (after bowels have moved) : 

Breakfast — Cereal, poached egg on toast, breakfast bacon, and cocoa 
or milk. 

Lunch — Squab or bird, potato chips or baked potato; cocoa. 

Supper — Mush and milk. 

Fifth day: 

Breakfast — Cereal, broiled steak, hashed brown or baked potato; milk. 
Lunch — Chicken, broiled or baked; mashed potatoes, sweet potatoes, 

asparagus tip salad. 
Supper — ^Milk toast. 



74 THE DISEASES OF CHILDREN 

Sixth day: 

Breakfast — Lamb chop, soft or poached egg, toast, cocoa and milk. 

Lunch — Junket, cocoa, spinach, potato. 

Supper — Baked apple or prunes, toast and milk. 
Bran muffins made of bran and flour, equal parts, are especially useful during 
this period as a prevention of constipation. 

Strict attention should be paid to her bowels, and at least 
one evacuation had daily. It must be remembered, however, 
that there are a few purgatives which are excreted through the 
milk. I have frequently noticed a purgative effect on the child 
when the mother has been taking cascara in some form. She 
must have at least a half hour's exercise in the open air daily 
and longer, if possible. 

If the child is satisfied after nursing and during the interval ; 
is gaining in weight regularly ; is happy and bright ; it may be 
asserted the milk is both up to the standard in quantity and 
quality. If the child is satisfied but a short while after nurs- 
ing, soon showing signs of hunger and the supply apparently 
adequate, then it is deficient in quality. If a milk is normal 
in amount, but deficient in certain ingredients, it can often be 
corrected and made to agree with the child. 

The Method of Nursing. Primipara should be instructed in 
the proper method of putting the child to the breast and holding 
it while nursing. During the puerperium, the mother lying 
partly on her side, the baby is put to the breast so it can readily 
grasp the nipple, which has been previously prepared, and one 
finger depresses the gland so that it will not press upon the 
nose and interfere Avith its breathing. The baby can either 
be supported upon the arm or lie flat upon the bed, the mother's 
arm being raised. 

Holding the breast so as not to obstruct the child's breathing 
is most important. I know of one normal baby when 12 hours 
old entirely asphyxiated from being allowed to bury its nose 
in the breast. 

When able to sit up to nurse, the mother occupies a low 
chair with a footstool, upon which rests the foot of the side 



INFANT FEEDING 75 

from which the baby nurses. The baby is held upon the arm, 
and leaning forward slightly the nipple is placed squarely in its 
mouth and not obliquely. 

Breast Milk. Breast millv is more bluish-white than yellow, 
and has been shown by Kerley and others to be faintly acid 
when tested with phenolphthalein. By others it is claimed 
breast milk is amphoteric, that is, it is alkaline to red litmus 
and acid to blue litmus. 

The following table is given by Holt, showing the composi- 
tion of breast milk : 

Aqerage Common healthy variations 
Per cent Per cent 

Fat 4.00 3.00 to 5.00 

Sugar 7.00 , 6.00 to 7.00 

Proteids 1.50 1.00 to 2.25 

Salts 0.20 0.18 to 0.25 

Water 87.30 89.82 to 85.50 

100.00 100.00 100.00 

Milk must be thought of as a homogeneous mixture, its chief 
ingredients being fat, sugar and proteids, and the percentages 
of these must be definite and stable if the milk will agree with 
the child. The usually accepted analysis of mother's milk 
shows, fat 3.5 per cent, sugar 6 per cent, proteids 1.5 per cent. 

An examination of breast milk by means of the Holt clinical 
milk set will show a more or less wide variation in the proteid 
and fat content in the same individual at different times of the 
day. There is always wider variation in these constituents than 
in the sugar, which is more or less constant. As already stated, 
the quantity of the milk may be sufficient for the child's needs, 
but the quality much below. The quantity obtained at a feed- 
ing can be determined by weighing the child before and after 
nursing, as was done in a number of cases by the writer, which 
were reported in the Archives of Pediatrics (May, 1893). 

Each baby was weighed with all of its clothes on before and 
directly after each nursing, with the nurse's and mother's assist- 
ance, being sure that the baby was kept awake during the entire 



76 



THE DISEASES OF CHILDREN 



20 minutes it was allowed to nurse. The weighing was care- 
fully done upon one of Fairbanks' scales which registered in 
half ounces with no change being made in clothing between 
weighings. Elimination of error was by this means made pos- 
sible which might occur from loss in weight by excrement from 
the child or from a difference in the texture of the napkins 
applied. Eight babies were weighed, 64 weighings being 

n 



cc 

6D"F 

450-^ 

♦ 00-^ 

350^ 

3DD^ 

250-1 

2D0 

l5D-= 

IDD 

5D 



ft 



CC 
6DT 

45Q-M 
40D-J 
35D^ 
3DD^ 
25D-B 



FIG. 23. holt's milk set. 



recorded. The babies were from two to ten days of age, healthy, 
and all weighing 6 pounds or more at birth. 



Age 
Days 

2 


Number of 

Weighings 

2 


Aver, weight o 

ingested milk 

Ounces 

1.25 


3 


13 


1.3 


4 


3 


1.0 


5 


10 


1.5 


6 


6 


1.25 


7 


13 


2.27 


8 


6 


2.25 


9 


8 


2.5 


10 


3 


2.5 



Given a case in which there was but little gain after a week's 
nursing or in which there is continued colic or curds passed in 



INFANT I^EEDING 



77 



large quantities, the breast milk should be examined clinically 
or if it is possible, chemically. The child should be put to the 
breast and allowed to nurse for three minutes, and a half ounce 
of milk either pressed or pumped from the breast, and if enough 
cannot be obtained from one side the other is treated in the 
same way. 

Holt's directions for the use of his milk set are as follows : 

The simplest method is by the cream-gauge. Although its results are only 
approximate, they are in most cases sufficiently accurate for cUnical purposes. 
The tube is filled to the zero mark with freshly drawn milk, which stands at 
room-temperature for twenty-four hours, when the percentage of cream is read 
ofT. The ratio of this to the fat is approximately five to three; thus 5 per cent, 
cream indicates 3 per cent, fat, etc. 

Sugar. The proportion of sugar is so nearly constant that it may be ignored 
in cHnical examination. 

Proteids. We have no simple method for determining clinically the amount 
of proteids. If we regard the sugar and salts as constant, or so nearly so as not 
to affect the specific gravity, we may form an approximate idea of the proteids 
from a knowledge of the specific gravity and the percentage of fat. We may 
thus determine whether they are greatly in excess or very low, which, after all, 
is the important thing. The specific gravity will then vary directly with the 
proportion of proteids, and inversely with the proportion of fat, i. e., high pro- 
teids, high specific gravity; high fat, low specific gravity. The application of 
this principle will be seen by reference to the accompanying table. 

woman's milk. 





SPECIFIC GRAVITY, 


CREAM, 


PROTEID 




70° F. 


24 HRS. 


CALCULATED. 


Average 


1.031 


i 

7 per cent 

8 per cent-12 


1.5 per cent 
Normal (rich 


Normal variations 


1.028-1.029 






per cent 


milk) 


Normal variations 


1.032 


5 per cent-6 


Normal (fair 






per cent 


milk) 


Abnormal variations. . . 


Low (below 1.028) 


High (above 10 


Normal (or 






per cent) 


sHghtly below) 


Abnormal variations . . . 


Low (below 1.028) 


Low (below 5 


Very low (very 






per cent) 


poor milk) 


Abnormal variations. . . . 


High (above 1.032) 


High 


Very high (very 
rich milk) 


Abnormal variations 


High (above 1.032) 


Low 

i 


Normal (or 
nearly so) 



Any specimen taken for examination should be either the middle portion of 
the milk, i.e., after nursing two or three minutes — or, better, the entire quantity 



78 THE DISEASES OF CHILDREN 



from one breast, since the composition of the milk will differ very much ac- 
cording to the time when it is drawn. The first milk is sUghtly richer in pro- 
teids and much poorer in fat. 



The problems to be met in the supervision of breast feeding 
are: 1. The increase of a too small supply. 2. Changing the 
character of the milk, (a) decreasing the proteids, (b) increas- 
ing the fat, (c) decreasing the fat. 3. To make serviceable 
nipples out of flat and depressed ones. 4. To supply an arti- 
ficial or adjuvant food in case of a good but too small supply 
from the breast. 5. To continue nursing should there be a 
suppurating mastitis, and retain the integrity of the gland 
after a subsidence of the inflammation. 

While, as a general rule, it may be stated the ideal food is a 
healthy breast milk, this is not always the case, for not infre- 
quently a mother has an abundant supply but secretes a milk 
which is unsuited to the needs of her own baby. These cases, 
however, are the exception, and it is infrequent that we find 
an unsuitable breast milk which cannot be changed by suitable 
remedial measures, hence I cannot refrain from saying a word 
against the unnatural mother who refuses to nurse her infant 
from purely selfish reasons, that she may have more time for 
society or pleasure. 'No physician should be a party to this 
or encourage it in any way, unless it can be plainly shown by 
most careful examination that the milk is imsuited and beyond 
remedial measures. 

While it may be a fact in the larger centers of population 
that mothers are unfeeling and unnatural enough to allow social 
obligations to interfere with nursing their babies, we believe 
that in the South and West this is seldom seen. There are 
undoubtedly cases where weaning must be decided upon, in 
which the child does not gain, or there is continual disagree- 
ment of the milk in spite of efforts to change the constituents. 
T have seen a number of cases in which the necessity for weaning 



Winslow 


Pjeiffer 


4.00 


2.04 


1.5 


3.74 


14.8 


0.71 


1.00 


0.25 


78.7 


88.23 



INFANT FEEDING 79 

has arisen early from insurmountable reasons. These have 
been enough to impress on me the unwisdom of voluntarily 
surrendering a good breast milk supply for the uncertainties of 
artificial feeding. 

The following analyses are given of colostrum: 



Fat 

Sugar 

Proteids 

Salts 

Water 

100.00 100.00 

Colostrum is more yellow in color than milk, does not coagu- 
late readily except on boiling and contains, in addition to the 
small regular size fat globules, the large granular colostrum 
corpuscles. These may persist in the milk until after the second 
week, but usually are not present after the tenth day. They 
recur during lactation, during menstruation and under the stress 
of great mental excitement, fear, anger, sorrow, sexual excite- 
ment, etc. When present abnormally, similar symptoms appear 
to those which occur soon after birth, diarrhea, and frequently 
vomiting. Compared with milk, colostrum has a higher per- 
centage of proteids and less sugar and fat. 

Besides this change which occurs, the milk may be influenced 
by any temporary illness of the mother, as influenza or grippe ; 
or any serious or prolonged illness, as typhoid fever, which 
would interrupt the nursing entirely. 

Certain drugs are said to be excreted in breast milk; as 
opium, belladonna, cascara, mercury, iodides, bromides and 
salicylates. The elimination of drugs in the milk is not suffi- 
ciently certain or exact to employ this method of medication 
in infants, nor enough to remove the child from the breast for, 
if any of these drugs were indicated in the mother. 



80 ■ THE DISEASES OE CHILDREN 

The following case illustrates colostrum disagreement: 

A mother began to menstruate four weeks after her delivery. 
Immediately her baby, which was doing well previously, began 
vomiting and purging. The second month the menstruation 
recurred with similar symptoms in the baby. 1 was called to 
see the child at this time and an examination of the breast 
milk showed it to be heavily loaded with colostrum corpuscles. 
The child was ill for several days, was weaned, and for one 
year was a constant care and anxiety, because of the difficulty 
of finding a suitable food or milk modification for it. 

There may be ample supply of good milk, but the absence of 
a serviceable nipple may prevent the child's obtaining it. This 
may be often seen, and it should be a routine practice to make 
as early an examination of the breasts and nipples of a preg- 
nant woman as possible, especially in primipara, in order 
to give instructions in the massage of flat and depressed nipples. 
By massage and training a very serviceable nipple can be made 
from an unpromising one if the treatment is begun early 
enough. The wearing of tight corsets or clothing should be 
advised against during pregnancy, but especially in the pres- 
ence of flat or depressed nipples. A careful inquiry should 
also be made of multipara in regard to their lactation history, 
as having a bearing on the possibility of nursing the new baby. 

A stationary weight, or a loss after the second week; vomit- 
ing, not simply a slight regurgitation ; colic ; continuous crying ; 
diarrhea, with green movements, containing curds and mucus, 
should be an indication for a close investigation of the breast 
milk, the frequency and time of nursing and the daily routine 
of the baby's life. 

A too high percentage of proteids is evidenced by colic, cry- 
ing, with a doubling up of the legs, tense abdomen, green stools 
containing mucus and curds. This very often occurs during 
the puerperium, but as soon as the mother gets up and is able to 
take the proper exercise, the increased proportion of proteids is 
generally decreased. Should this relatively high percentage of 
proteids with low percentage of fat persist, and the plentiful 



INFANT FEEDING 81 

supply keep up, much help can be had from pumping or milking 
out the foremilk from the breast, the child being allowed to 
nurse only the middlemilk and strippings. Taking the child 
from the breast before it has finished nursing and giving it a 
small quantity of barley water, previously dextrinized, from a 
bottle, will often relieve the colic, lessen the diarrhea and make 
the curds smaller. 

Too much fat, which I have met but a few times, causes 
vomiting and diarrhea, with few or no curds in the movements. 
If too much fat is present there may be found in the stools 
small, round masses which resemble curds very much, but are 
smooth and soft and not so white as curds. 

A too small milk supply calls for active treatment. It is 
evidenced by a stationary weight or a loss in the weight of the 
infant; crying within a few minutes after leaving the breast 
and sucking vigorously on its fists after nursing. If the de- 
ficiency in supply is the only fault, it may frequently be 
increased by such galactagogues as nutrolactis or somatose, free 
drinking of milk, cocoa or chocolate and the cereal gruels. 

These gruels may be made of oatmeal, barley or cornmeal. 
After thorough cooking for several hours, they are ready to serve, 
enough milk being added so they can be drank from a cup or 
eaten with a spoon. 'No article of diet so stimulates the func- 
tion of the gland as cow's milk, and in connection with the 
cereals excellent results are seen. 

Alcoholic beverages are to be avoided, as they encourage the 
secretion of a milk with a deficiency in its life-giving proper- 
ties and an increase in the watery element. 

If these measures do not correct the difficulty, the child should 
be put on a modified cow's milk, or suitable formula, in addi- 
tion to the nursing, giving at first 1 or 2 drachms to an infant 
of four weeks immediately after a breast feeding, gradually 
increasing the amount as indicated. This will generally suffice 
to obtain a satisfactory gain in its weight. 

With a good milk supply, regularity of nursing, infrequent 



82 THE DISEASES OF CHILDREN 

or no night nursing, a child will generally do well; a good 
supply with a disregard of these requisites will result, perhaps, 
in serious digestive derangements. Should a combined breast 
and artificial feeding be necessary, the one or two night feed- 
ings should be breast milk if for no other reason than the con- 
venience to the parents. The only objection to this is the possi- 
bility of the mother falling asleep and allowing the child to 
lie with the nipple in its mouth for several hours at a time. 

To increase the quantity of the milk, give more nutritious 
diet, more milk and cereal gruels. 

To increase fat, give milk and meat. 

To decrease fat, give less meat and milk and increase the 
water. 

To increase the proteids, give more meat and eggs; lessen 
exercise. 

To decrease proteids, increase exercise to point of fatigue 
and decrease meat. 

Weaning. It is well to begin weaning an infant at about 
10 months of age; with at first one feeding a day, then two, 
gradually displacing the nursings by an additional bottle feed- 
ing, until at the end of the first year entire weaning has been 
accomplished. 

The weaning may be accomplished suddenly, but frequently 
not without considerable gastric and intestinal disturbance 
being caused in the child. 

Combined Feeding. If it is apparent that a child is not gain- 
ing rapidly while nursed exclusively, by giving one or two arti- 
ficial feedings a day, of modified cow's milk, very good results 
can frequently be obtained. 

As when entire artificial feeding is begun, so when only par- 
tially fed, a much w^eaker formula should be given than neces- 
sary for the child's needs to begin with, and gradually increase 
the strength of the formula until one is reached upon which it 
will be contented, and will gain in weight. 

It is frequently a very good plan when a child is a few weeks 



INFANT FEEDING 83 

old to give it one bottle a day, in order to accustom it to an 
artificial food, and also to enable the mother to have a few 
extra hours of recreation, occasionally, if the demand arises. 

Cow's Milk. Because of the universal supply of cow's milk, 
and the fact that it contains the same general constituents of 
and can be modified to nearly resemble mother's milk, it is the 
best substitute for normal mother's milk, when artificial feeding 
is necessary. A comparative analysis of mother's and cow's 
milk is here given: 

Mother's Cow's 

Milk Milk 

Fat 4.0 4.0 

Sugar 7.0 4.0 

Proteids 1.5 3.5 to 4.0 

^o food product is so capable of contamination as milk, or as 
little average intelligence used as in its production and care. 
How common is the saying, especially in cities, when the diet of 
a sick child is under discussion : ^'Take it to the country where 
you know good milk can be obtained." It is a fact that but 
few people in the country, unless in the scientific dairy business, 
know the first principles of the production and handling of 
milk. 

Certified Milk. Eealizing this fact, and that pure milk, espe- 
cially for infants, sick children and invalids, was a necessity, 
Dr. Henry L. Coit of l^ewark, IN". J., in 1894, suggested the 
plan of securing a dairyman who would produce milk and 
handle it in a scientific manner, according to the rules of a finan- 
cially disinterested commission. This was done, and the product 
of this dairy was termed ^'Certified Milk," the term being regis- 
tered at the Patent Ofiice in Washington by the dairyman, Mr. 
Stephen Francisco, and Dr. Coit. They have very generously 
allowed the use of the term by similar commissions, and a num- 
ber of the larger cities have such a supply. In 1907, at Atlantic 
City, was formed the American Association of Medical Milk 
Commissions, with Dr. Coit as its first president, its member- 
ship composed of the members of milk commissions throughout 



84 



THE DISEASES OF CHILDREN 




INFANT FEEDING 85 

the country, and dairy scientists in this conntry and abroad. 
This association will do much toward systematizing and making 
more uniform the rules and standards and working methods of 
commissions and popularizing this plan of obtaining at least 
one pure supply of milk in the larger centers of population. 

Kentucky has a law which limits the use of the term ''Certified 
Milk" to a milk commission regularly appointed by a county 
medical society. This effectually prevents the use of the term 
by a dairyman, for commercial reasons, without producing the 
milk according to the requirements of a commission. This law 
is as follows: 

An act for preventing the manufacturing and sale of adulterated or mis- 
branded foods, drugs, medicines and liquors, and providing penalties for viola- 
tions thereof. 

Be it enacted by the General Assembly of the Commonwealth of Kentucky: 

SECTION 1. That it shall be unlawful for any person, persons, firm or corpor- 
ation within this State to manufacture for sale, produce for sale, expose for sale, 
have in his or their possession for sale or to sell any article of food or drug which 
is adulterated or misbranded within the meaning of this act; and any person or 
persons, firm or corporation who shall manufacture for sale, expose for sale, 
have in his or their possession for sale or sell any article of food or drug which 
is adulterated or misbranded within the meaningof this act, shall be fined not 
less than ten dollars nor more than one hundered dollars, or be imprisoned not 
to exceed fifty days or both such fine and imprisonment. Provided, that no 
article of food or drug shall be deemed misbranded or adulterated within the 
provisions of this act when intended for shipment to any other State or country, 
when such article is not adulterated or misbranded in convict with the laws of 
the United States; but if said article shall be in fact sold or offered for sale for 
domestic use or consumption within this State, then this proviso shall not 
exempt said article from the operations of anj'- of the other provisions ot this 
act. 

SECTION 2. That the term food, as used in this act, shall include every article 
used for or entering into the composition of food or drink for men or domestic 
animals, including all liquors. 

SECTION 3. For the purpose of this act, an article of food shall be deemed 
misbranded: 

First. If the package or label shall bear any statement purporting to name 
any ingredient or substance as not being contained in such article, which state- 
ment shall not be true in any part; or any statement purporting to name the 
substance of which such article is made, which statement shall not give fully 
the name or names of all substances contained in any measurable quantity. 

Second. If it is labeled or branded in imitation of or sold under the name of 



86 THE DISEASES OF CHILDREN 

another article, or is an imitation either in package or label of another sub- 
stance of a previously established name; or if it be labeled or branded so as to 
deceive or mislead the purchaser or consumer with respect to where the article 
was made or as to its true nature and substance or as to any identifying term 
whatsoever whereby the purchaser or consumer might suppose the article to 
possess any property or degree of purity or quality which the article does not 
possess. 

Third. If in the case of certified milk, it be sold as or labeled "certified 
milk, " and it has not been so certified under rules and regulations by any 
county medical society, or if when so certified, it is not up to that degree of pur- 
ity and quality necessary for infant feeding. 

In a local Louisville court, conviction and fine was obtained 
in 1908 of a dairyman, under the State Pure Food laws, who 
had sold milk labeled "Certified Milk/' which had not been 
certified to by the Jefferson County Milk Commission, the prose- 
cution being because of misbranding and a tendency to deceive 
the public. 

The following rules of the New York County Medical Milk 
Commission, and those of the Jefferson County (Ky.) Medical 
Milk Commission, are given as samples of working rales, both 
of which yield the very best results : 

Rules for the Producer. (1) The Barnyard. The barnyard should be 
free from manure and well drained, so that it may not harbor stagnant water. 
The manure which collects each day should not be piled close to the barn, but 
should be taken several hundred feet away. If these rules are observed not 
only will the barnyard be free from objectionable smell, which is always an 
injury to the milk, but the number of flies in summer will be considerably dimin- 
ished. These flies, in themselves, are an element of danger; for they are fond 
of both filth and milk, and are liable to get into the milk after having soiled 
their bodies and legs in recently visited filth, thus carrying it into the milk. 
Flies also irritate cows, and by making them nervous reduce the amount of 
their milk. 

(2.) The Stable. In the stable the principles of cleanliness must be strictly 
observed. The room in which the cows are milked should have no storage loft 
above it; where this is not feasible, the floor of the loft should be tight, to pre- 
vent the sifting of dust into the stable beneath. The stable should be well ven- 
tilated, lighted and drained, and should have tight floors, preferably of cement. 
They should be white-washed inside at least twice a year, and the air should 
always be fresh and without bad odor. A sufficient number of lanterns should 
be provided to enable the necessary work properly to be done during dark hours. 
There should be an adequate water-supply and the necessary wash-basins, soap, 



INFANT FEEDING 



87 



and towels. The manure should be removed from the stalls twice daily, 
except when the cows are outside in the fields the entire time between the morn- 
ing and afternoon milkings. The manure gutter must be kept in a sanitary con- 
dition,, and all sweeping and cleaning must be finished at least twenty minutes 
before milking, so that at that time the air may be free from dust. 




FIG. 



:o. CERTIFIED DAIRY NO. O SHIPPING CASE. PACKED, 
TO CLOSE FOR SHIPMENT, 



ICED AND READY 



(3.) Water-supply. The whole premises used for dairy purposes^ as well as 
the bam, must have a supply of water absolutely free from any danger of pollu- 
tion with animal matter, sufficiently abundant for all purposes, and easy of 
access. 

(4.) The Cows. The cows should be examined at least once a year by a 
skilled veterinarian. Any animal suspected of being in bad health must be 
promptly removed from the herd and her milk rejected. Xever add an animal 



88 THE DISEASES OF CHILDREN 

to the herd until it has been tested for tuberculosis and it is certain that it is free 
from disease. Do not allow the cows to be excited by hard driving, abuse, loud 
talking or any unnecessary disturbance. Do not allow any strongly flavored 
food, like garlic, which will affect the flavor of the milk, to be eaten by the cows. 

Groom the entire body of the cow daily. Before each milking wipe the udder 
with a clean, damp cloth, and, when necessary, wash it with soap and clean 
water and wipe it dry with a clean towel. Never leave the udder wet, and be 
sure that the water and towel used are clean. If the hair in the region of the 
udder is long and not easily kept clean, it should be clipped. The cows must 
not be allowed to lie down, after being cleaned for milking, until the milking 
is finished. A chain or rope must be stretched under the neck to prevent this. 

All milk from cows sixty days before and ten days after calving must be 
rejected. 

(5.) The Milkers. The milker should be personally clean. He should neither 
have nor come in contact with, any contagious disease while employed in milk- 
ing or handling milk. In case of any such illness in the person or family of any 
employee in the dairy, such employee must absent himself from the dairy, 
until a physician certifies that it is safe for him to return. 

Before milking, the hands should be thoroughly washed in warm water with 
soap and a nail-brush and well dried with a clean towel. On no account should 
the hands be wet during the milking. 

The milking should be done regularly at the same time, morning and evening, 
and in a quiet, thorough manner. Light-colored washable outer garments 
should be worn during milking. They should be clean and dry, and when 
not in use for this purpose should be clean kept in a place protected from dust. 
Milking-stools must be kept clean. Iron stools, painted white, are recom- 
mended. 

(6.) Helpers Other than Milkers. All persons engaged in the stable and 
dairy should be reliable and intelligent. Children under twelve years should 
not be allowed in the stable during milking, since in their ignorance they may 
do harm, and from their liability to contagious diseases they are more apt than 
older persons to transmit them through the milk. 

(7.) Small Animals. Cats and dogs must be excluded from the stable during 
the time of milking. 

(8.) The Milk. The first few streams from each teat should be discarded, 
in order to free the milk-ducts from milk that has remained in them for some 
time and in which bacteria are sure to have multiplied greatly. If, in any 
milking, a part of the milk is bloody or stringy or unnatural in appearance, the 
whole quantity of milk yielded by that animal must be rejected. If any acci- 
dent occurs by which the milk in a pail becomes dirty, do not try to remove the 
dirt by straining, but reject all the milk and cleanse the pail. The milk pails 
used should have an opening not exceeding eight inches in diameter. 

Remove the milk of each cow from the stable, immediately after it is 
obtained, to a clean room and strain it through a sterilized strainer. 

The rapid cooling of milk is a matter of great importance. The milk should 
be cooled to 45° F. within one hour. Aeration of pure milk beyond that obtained 
in milking is unnecessary. 



INFANT FEEDING 89 

All dairy utensils, including JDottles, must be thoroughly cleansed and steril- 
i zed. This can be done by first thoroughly rinsing in warm water, then wash- 
ing with a brush and soap or other alkahne cleansing material and hot water, 
and thoroughly rinsing. After this cleansing, they should be sterilized with 
boihng water or steam, and then kept inverted in a place free from dust. 

(9.) The Dairy. The room or rooms where the bottles, milkpails, strainers, 
and other utensils are cleaned and sterilized should have at least a separate 
entrance, and be used only for dairy purposes, so as to lessen the danger of 
transmitting through the milk contagious diseases which may occur in the 
home. 

Bottles, after filling, must be closed with sterilized discs and capped so as to 
keep all dirt and dust from the inner siu-face of the neck and mouth of the bottle. 

(10.) Examination of the Milk and Dairy Inspection. In order that the deal- 
ers and the Commission may be kept informed of the character of the milk, spec- 
imens taken at random from a day's supply must be sent weekly to the Research 
Laboratory of the Health Department, where examinations will be made by 
experts for the Commission, the Health Department having given the use of its 
laboratories for this purpose. 

The Commission reserves to itself the right to make inspections of certified 
farms at any time and to take specimens of milk for examination. It also 
reserves the right to change its standards in any reasonable manner upon due 
notice being given the dealers. 

The following are tlie rules of the Jefferson County (Ky-) 
Medical Milk Commission: 

A MILK 

The milk taken from the delivery wagon shall fulfil the following conditions: 

(1.) It shall be free from pus and pathogenic organisms, and contain not 
more than 10,000 bacteria to the cubic centimeter. 

(2.) The reaction shall be neutral or slightly acid. 

(3.) The milk shall contain not less than 3 nor more than 4 per cent, of pro- 
teids, not less than 4 nor more than 5 per cent, of sugar, not less than 3.5 nor 
more than 4,5 per cent, of fat. Producers furnishing a milk which fulfils the 
other requirements of the Commission, but with a higher fat content than above 
may also have their milk certified, as containing more than 4.5 per cent, of fat. 

(4.) The milk shall be free from preservatives, coloring matters and other 
contaminations, and it shaU not have been subjected. to the action of heat. 

(5.) The milk shall be cooled to a temperature below 45° Fahrenheit within 
one quarter of an hour of the time of milking, and shaU be kept below this tem- 
perature up to the time of delivery; it shall not have been frozen. 

(6.) The milk shall be delivered in glass bottles, sealed in a manner satisfac- 
tory to the Commission. 

B DAIRY 

The barn where the cows are kept, the dairy, and the surroundings shall be 
in a clean and sanitary condition, satisfactory to the Commission. 



90 THE DISEASES OF CHILDREN 

The cows shall be healthy, and free from tuberculosis, as shown by the tuber- 
cuHn test. The test shall be applied at or shortly before admission to the herd, 
and at least once each year thereafter, in a manner and by a person satisfactory 
to the Commission. 

The employees shall be healthy and cleanly in their persons and habits, and 
shall use freshly laundered white suits when milking. They shall not suffer 
from, or have been recently exposed to, any infectious disease. 

Gurler pails shall be used with sterile gauze and absorbent cotton. 

The feed for the cattle must be clean and wholesome. 

The floor and feeding troughs shall be of concrete, 500 cubic feet of space shall 
be allowed for each cow and not less than 4 square feet of glass for each cow. 

The barn shall be thoroughly ventilated and shall be ceiled on roof and 
sides and shall not communicate directly with any place where other animals 
are housed or with the milk house. 

It is desirable to have a separate milking room, and also a separate barn to 
which sick cows must be removed. 

There must be a sufficiency of spring or pure running water on the farm avail- 
able for the cows. 

Manure must be removed from the barn twice daily and removed from the 
vicinity of the barn daily. 

There must be efficient means of sterilizing bottles, milking pails, etc., on the 
farm. 

The cows shall be thoroughly brushed and the udders rubbed with a damp 
cloth at least twenty minutes before milking. 

C — INSPECTION 

The milk from each dairy certified by the Commission shall be examined at 
least once each week, both bacteriologically and chemically. Samples for 
examination shall be taken from the delivery wagons by an agent of the Com- 
mission, without previous notice to the proprietors. 

In case examination shows that the milk does not fulfil the conditions set by 
the Commission, the dairy may have, at the discretion of the Commission, a 
re-examination made within a short time. 

Each dairy furnishing certified milk shall be inspected at least once a month 
by an inspector appointed by the Commission. The health of the employees 
at the dairy shall be certified to, at least once a month, by a physician appointed 
by the Commission. 

The Commission reserves the right to change these requirements at its dis- 
cretion. 

D CERTIFICATION. 

If both the dairy and the milk it produces fulfil the foregoing requirements, 
a certificate will be issued to the proprietor of said dairy, good for a period of 
one month. 



INFANT FEEDING 91 

Excretion of Foreign Matter in Milk. Inflammatorj condi- 
tions of tiie udder may result in contamination of the milk by 
the presence of pus and microorganisms from the affected parts. 
Certain foods may cause a decided odor as well as taste to cow's 
milk, as when they are fed on garlic or lupines, the latter im- 
parting a bitter taste to the milk. 

Changes in Milk Produced by Bacteria and Other Microorgan- 
isms. The commoner and well-known changes which occur in 
milk as the result of the action of bacteria and other micro- 
organisms are as follows : The souring of milk, with curdling, 
due to action of the lactic acid bacteria; the putrefaction of 
milk, with production of various odors; the coloring of milk; 
the production of ropy milk. 

The fermentation caused by the lactic acid bacteria in milk, 
kept at ordinary temperature, is well known. The result of 
this fermentation is souring and curdling of the milk, and all 
other bacterial changes are temporarily stopped. As a result 
of the infection of the milk by other organisms, abnormal fer- 
mentations take place, causing changes in the color, odor and 
taste of the milk. A blue discoloration of the milk is due to 
its contamination by bacteria, known as the Bacillus Cyan- 
ogenes, and they exert their peculiar effect only after the milk 
has become sour. Others describe a red milk, but this can 
usually be traced to a cow with diseased or injured udders. 
Slimy or ropy milk is due to the organism known as B. lactis 
viscosus, and is found in the water supply of the place. 

The first few drops of milk from a healthy udder may con- 
tain a few bacteria, but the rest of the mill?: direct from the 
udder should be sterile. Milk is one of the best culture mediums 
and it may readily become contaminated from the air, the cow's 
skin, hair and udder, the milker's hands or clothes, or the 
utensils with which the milk comes in contact. A clean, cold 
milk, from a healthy herd, will remain safe until consumed if 
handled properly. The chief aim being to keep dirt out of the 
milk, and as much comes from the cow's skin and tail, the 



92 THE DISEASES OF CHILDREN 

buckets which have a small opening at the top and more at the 
side than in the middle, allow the milk to be drawn into it easily 
and prevent the dirt and hair dropping into it. 

If milk properly produced and handled has been cooled 
directly after milking to 45° F., and kept at this temperature, 
the bacteria per cubic centimeter (20 drops) should not exceed 
10,000, while ordinary market milk will contain from 500,000 
to several million per cubic centimeter. Clean milk, cooled and 
kept cold, will not have a great increase in bacterial content at 
the end of several days, and it can be found sweet at the end of a 
number of days. I have drank such milk kept in this way 
when 21 days old, and milk sent to the Paris Exposition in 
1900 from Illinois, 'New Jersey and J^ew York, was sweet at 
the end of 14 days. This milk had been kept cold, and was 
clean at the first milking. 

The number of bacteria in milk free from preservatives is 
a direct indication of the cleanliness employed at the dairy in 
the production of the milk, the temperature at which it has 
been kept and its age. 

Standards of bacterial contents are being adopted in many 
of the large cities. Certified milk has a limiting standard of 
10,000 per cc. ; inspected milk 100,000 per cc. (50,000 per cc. 
in Louisville), and several cities for market milk 500,000. 
Hence the bacterial count of milk is a most important procedure. 

The following method for bacterial count of milk is em- 
ployed by Dr. Rosenau, Director of the Hygienic Laboratory, 
Marine Hospital Service, Washington, D. C. : 

The samples were always collected in the original containers, 
either pint or quart bottles being purchased for our purposes. 
Some of these samples were obtained from the wagon on the 
street, others from the dairy, and still others were obtained 
from houses in various parts of the city, at once after being 
delivered in the usual course of trade. It is therefore believed 
that the samples examined fairly represent the average milk 
obtained by the householder. The samples were collected early 



INFANT FEEDING 93 

in the morning and at once placed in a metal container filled 
with cracked ice. From six to eight samples were collected 
each morning from various parts of the city, and rarely more 
than two hours elapsed from the collection of the first sample 
to the time it was received in the laboratory. The temperature 
was taken with a good thermometer at the time the sample was 
collected, but always from a different bottle, which was after- 
wards used for chemical purposes. 

It was noted that after the milk stood on ice for some time 
that there might be a difference of 6° to 8° between the top 
and the bottom layers of the milk in a pint bottle. The milk 
was always shaken well in order to mix the cream and to help 
break up the bacterial clumps before the bottle was opened, 
which was done with tlie usual bacteriologic precautions. For 
ordinary market milk the following dilutions were made : 

One cubic centimeter plus 99 cc. sterile water. 

One-tenth cubic centimeter of this was used for the first plate, 
which represented 1 :1000. 

One-half cubic centimeter of the first dilution was then added 
to 49.5 cc. of sterile water. One cubic centimeter of this dilu- 
tion when plated represented 1:10,000, and 0.1 cc. of this dilu- 
tion represented 1 :100,000. 

The dilutions were vigorously shaken at least 25 times in 
accordance with the standard methods for water analysis, in 
order to obtain uniform suspension of the bacteria. Sterile 
distilled water was used as a diluent. 

The final dilution was measured directly into a petri dish 
and agar poured at a temperature of between 40° and 45 °C. 
in the usual way. 

After the plates were well set they were grown at 37° C, 
which temperature appears not only to favor the maximum 
growth of bacteria ordinarily found in the milk, but has the 
additional advantage of favoring the kinds of bacteria belonging 
to the pathogenic class. The plates were counted at the end 
of 24 hours, although by that time the maximum growth had 



94 THE DISEASES OP CHILDREN 

not appeared. Only those colonies were counted which were 
visible to the naked eye or could be seen with a low-power mag- 
nifying glass. Three plates were always made from each 
sample, one from each dilution. Plates that became spoiled 
owing to spreading of the surface growths over them, irregular 
distribution or excessive numbers, were discarded. The counts 
were ahvays taken when possible from plates containing 200 
or less bacteria per plate, the reading being reduced to round 
numbers. 

The composition of the media used for this work was 1.5 
per cent agar and an acidity of plus 1.5 to phenolphthalein as an 
indicator. 

Market Milk. Cow's milk, to be fit for consumption by 
infants and children should answer the following requirements : 
It should be clean; from a healthy herd which has been tuber- 
culin tested; cooled immediately after milking; bottled at once 
and sealed ; contain no preservatives ; be of standard and definite 
chemical analysis and kept cold until delivered to the con- 
sumer. Milk from one cow should never be used for infant 
feeding, but the mixed milk from several cows or a herd. 

Ordinary city market milk is not fit for consumption. It 
is shipped to the city in large cans, hauled through the streets 
in an uncovered wogan, to the central distributing station, there 
bottled (usually in unclean bottles') and distributed, no ice 
being ever near it. Some bottle the milk in delivery wagons 
from large cans, the bottles being dusty and unsterilized. This 
milk contains many million bacteria, and rapidly sours in warm 
weather, even if kept on ice. 

Milk from cows fed upon distillery waste or slop, or brewers' 
grain or ensilage in any state of putrefaction or fermentation, 
is unfit for consumption. Cows so fed suffer from a diarrhea, 
and the stables housing them are filthy beyond description. 
Milk produced in such barns contains myriads of bacteria. 

Tuberculosis. Since Koch advanced his dictum in 1901 that 
bovine tuberculosis was not transmissible to man, scientists of 



INFANT FEEDING 



95 



the world have been at work to disprove it. This has unques- 
tionably been done. Undoubted cases of direct transmission 
have been recorded by Jensen,^ a few of which may be 
mentioned : 

1. The 17-year-old daughter of Prof. Gosse died of abdom- 
inal tuberculosis after drinking milk from cows affected with 
udder tuberculosis. Other -sources of infection could not be dis- 
covered. 




FIG. 26. A SAMPLE OF THE UNSUSPECTED BUT DANGEROUS TUBERCULAR COW. 
REJECTED BY THE VETERINARIAN. 

2. Oliver's observation concerns one of the best-proven 
cases of transmission by milk. In a boarding school 12 young 
girls became ill with signs of intestinal tuberculosis and ■Q.ve 
of them died. All came from healthy families and no source 
of infection was found but one cow which supplied milk for 
the school, and was shown to be affected with tuberculosis of 
the udder. 

3. Demme has reported the following: In the children's 
hospital, Bern, four children died of intestinal and mesenteric 
glandular tuberculosis. He was able to exclude all other sources 



* Jensen's Milk Hygiene. 



96 THE DISEASES OF CHILDREN 

of infection and to prove that the milk came from tuberculous 
cows. 

4. Hills tells of a 21-months-old child that was affected 
with intestinal tuberculosis three months after making an eight- 
day visit to an uncle where it had drank the milk of a cow 
having advanced tuberculosis. The child died of tuberculosis. 
Other sources of infection were excluded and another child fed 
only with sterilized milk remained healthy. 

5. Ernst reports that three children of the same family died 
of tuberculosis after drinking milk from a cow that died of 
general tuberculosis with udder involvement. 

Mohler-^- states that: 

The finding of the bovine type of tubercle bacillus in human 
lesions is the most direct and positive proof that tuberculosis 
of cattle is responsible for a certain amount of tuberculosis in 
the human family. Numerous experiments with this object in 
view have already proven this fact. Thus the German Commis- 
sion on Tuberculosis examined 56 different cultures of tubercle 
bacilli of human origin and found six which were more virulent 
than is usual for human tubercle bacilli, causing marked lesions 
of tuberculosis in the cattle inoculated with them, and making 
over 10 per cent of the cases tested that were affected with a 
form of tuberculosis which, by Koch's own method, must be 
classified as of bovine origin. The bacilli, with the exception 
of a single group, were all derived from the bodies of children 
under seven years of age, being taken from tubercular ulcers 
in the intestines, the mesenteric glands or from the lungs. 

In a similar series of tests conducted by the British Royal 
Commission on Tuberculosis, 60 cases of the disease in the 
human were tested, with the result that 14 cases were claimed 
by this commission to have been infected from bovine sources. 
Eavenel reports that of ^ve cases of tuberculosis in children two 
received their infection from cattle. Theobald Smith has also 
reported on one culture of the bovine tubercle bacillus obtained 

* Bulletin 14, Hygienic Laboratory. 



INFANT FEEDING 9< 

from the mesenteric glands of a child out of five cases examined, 
and, according to a recent paper by Goodale, Smith has recently 
been at work on seven other cultures from different children, 
four of which conformed to his idea of tubercle bacilli emanating 
from cattle. Of four cases of generalized tuberculosis in chil- 
dren examined in the Biochemic Division of the Bureau of 
Animal Industry, two were found to be affected with very viru- 
lent organisms, which warranted the conclusion that such chil- 
dren had been infected from a bovine source. The Pathological 
Division of the same Bureau has likewise, out of the nine cases 
of infantile tuberculosis examined, obtained two cultures of 
tubercle bacilli that could not be differentiated from bovine 
cultures. In Europe so many similar instances of bovine 
tubercle bacilli having been recovered from human tissues are 
on record that it appears entirely proven that man is susceptible 
to tuberculosis caused by animal infections, and while the pro- 
portion of such cases cannot be decided with even approximate 
accuracy, it is nevertheless incumbent upon us to recommend 
such measures as will guard against these sources of danger 
when enforced. 

Tuberculosis is markedly prevalent throughout the United 
States in dairy cattle. It is estimated that in certain sections 
it affects from 20 to 60 per cent of the members of all herds. 
In Washington 16.9 per cent of 1538 cattle tested reacted to 
the test. It is conceded by all that local tuberculosis in the 
udder will result in contamination of the milk with tubercle 
bacilli, and that in other forms of bovine tuberculosis, as of the 
intestine and lungs, great quantities of bacilli are excreted by 
the discharges which may contaminate the milk. It has been 
found, for instance, that 70 per cent of all milk examined in 
Washington, D. C, contained dirt, and microscopic examina- 
tion showed it to be fecal in character, hence the frequency of 
contamination by tubercle bacilli. 

The tuberculin test, tuberculin being the sterilized and fil- 
tered glycerine extract of cultures of tubercle bacilli, in the 



98 THE DISEASES OF CHILDREN 

hands of competent men is practically an infallible test, and a 
cow which reacts to the test should be slaughtered at once. This 
should be under State indemnification, for without State aid 
the disease will not be eradicated. 

If the injected animal is normal the result of the tuberculin 
injection will be negative, that is, she will not show a rise in 
temperature. 

The ''test" is applied as follows: The temperature of the cow 
is taken in the rectum at two-hour intervals for 12 hours and the 
variations noted. That night about 9 p. m. the tuberculin is 
injected hypodermically in a shaved portion of the skin of the 
hip. The following day the temperatures are taken again and 
recorded, as nearly as possible every two hours, and continued 
for 20 hours. 

In the markedly tubercular a small dose of the tuberculin 
may show no reaction. A tolerance is shown for the tuberculin 
for six weeks after an injection. 

A reaction may be found in advanced pregnancy, during 
the oestrum and in concurrent diseases, as inflammations of the 
lungs, intestines or uterus; or when a sudden change is made 
in the feeding during the test. 

In reading the temperatures taken after the test, a rise of 
2° is not noted. It should go above 103.8° F. Cows reacting 
should be slaughtered at once and examined by veterinary ex- 
perts capable of detecting minute as well as gross macroscopic 
lesions. 

Salmon concludes as follows, regarding the tuberculin test: 

1. That the tuberculin test is a wonderfully accurate method 
of determining whether an animal is affected with tuberculosis. 

2. That by the use of tuberculin the animals diseased with 
tuberculosis may be detected and removed from the herd, thereby 
eradicating the disease. 

3. That tuberculin has no injurious effect upon healthy 
cattle. 

4. That the comparatively small number of cattle which 



INFANT FEEDING 99 

have aborted, suffered in health or fallen off in condition after 
the tuberculin test, were either diseased before the test was made 
or were affected by some cause other than the tuberculin. 

A cow may be dangerously tubercular as sho^\m by Schroeder"^ 
long before she shows clinical evidences of tuberculosis. She 
may not cough, may eat well, calve, and in every way appear 
normal, yet be excreting millions of bacilli before the presence 
of tuberculosis is determined by the tuberculin test. 

Epidemics Due to Milk. Specific organisms may contaminate 
milk and cause epidemics among its users. Typhoid fever is 
more frequently spread through the medium of water, next by 
milk. Jensen records 90 epidemics of typhoid in Copenhagen, 
from 18T8tol896. I have traced one in Louisville where there 
were 54 cases in a small territory, 44 of whom used milk from 
one dairy. In one family only one person used unboiled milk 
and she contracted typhoid. Typhoid bacilli were demonstrated 
by the late Dr. Louis Yissman in the water used on this dairy- 
man's place for can washing. Diphtheria may be milk borne, 
also. Smithbank and E'ewmanf record 100 cases in Ashtabula, 
Ohio, affected with diphtheria in 1894. Milk was delivered 
to all by the same dairyman. A farm hand had a sore throat, 
and he had assisted at the work of the dairy while so suffering. 

Scarlet fever epidemics have undoubtedly been so traced. 
Touching this point of epidemics due to milk, Busey and 
Kober give a summary of the epidemics compiled by them as 
follows ::{: 

TYPHOID FEVER EPIDEMICS. 

Mr. E. Hart tabulated 50 epidemics of typhoid fever and we have collected 
88, making a total of 138 epidemics traceable to a specific pollution of the milk, 
the main facts of which are presented in a subjoined table. In 109 instances 
there is evidence of the disease having prevailed at the farm or dairy. In 54 
epidemics the poison reached the milk by soakage of the germs into the well 
water with which the utensils were washed and in 13 of these instances the 

* Bulletin 114, U. g. B. A. I. 

t Jensen. 

:!: Hygienic Laboratory Bulletin 14. Marine Hospital Service- 



100 THE DISEASES OF CHILDREN 

intentional dilution with polluted water is admitted. In 6 instances the 
infection is attributed to the cows drinking or wading in sewage-polluted water. 
In three instances the infection was spread in ice cream prepared in infected 
premises. In 21 instances the dairy employees also acted as nurses. In 6 
instances the patients while suffering from a mild attack of enteric fever, or 
during the first week or ten days of their illness continued at work and those 
of us who are familiar with the personal habits of the average dairy boy will 
have no difficulty in surmising the manner of direct digital infection. In one 
instance the milk tins were washed with the same dishcloth used among the 
fever patients. In one instance the disease was attributed to an abscess of 
the udder, in another to a teat eruption, and in one to a febrile disorder in the 
cows. Four were creamery cases. In one the milk had been kept in the sick 
room. 

SCARLET FEVER EPIDExMICS. 

Mr. Hart collected 15 epidemics of milk scarlatina, and we have tabulated 
59, making a total of 74 epidemics spread through the medium of the milk 
supply, the details of which will be found in Table No. II. 

In 41 instances the disease prevailed either at the milk farm or dairy. In 6 
instances persons connected with the dairy either lodged in or had visited 
infected houses. In one the milkman had taken his can into an infected house. 
In 20 instances the infection was attributed to disease among the milch cows; 
in 4 of these the puerperal condition of the animal is blamed. In 9 instances 
disease of the udder or teats was found. In one instance the veterinarian 
diagnosed a case of bovine tuberculosis. In 6 instances there was loss of hair 
and casting of the skin in the animal. In No. 68 the cattle were found to be 
suffering more or less from febrile disturbance. In 10 instances the infection 
was doubtless conveyed by persons connected with the milk business, while 
suffering or recovering from an attack of the disease and in at least 8 cases by 
persons who also acted as nurses. In three instances the milk had been kept 
in the cottage close to the sick room. In one the cows were milked into an 
open tin can which was carried across an open yard past an infected house, 
and in one the milkman had wiped his cans with white flannel cloths 
(presumably infected) which had been left in his barn by a peddler. Two 
appear to have been instances of mixed infection of scarlet fever and diph- 
theria, 

DIPHTHERIA EPIDEMICS. 

Mr. Hart collected 7 epidemics of milk diphtheria and we have added 21 
-more. In 10 of these 28 instances diphtheria existed at the farm or dairy, and 
in 10 instances the disease is attributed directly to the cows having garget, 
chapped and ulcerative affections of the teats and udder, while in one the cows 
were apparently healthy but the calves had diarrhea. In one case one of the 
dairymaids suffered from a sore throat of an erysipelatous character, and in one 
the patient conti»ued to milk while suffering from diphtheria. In one, one of 
the drivers of the dairy wagons was suffering from a sore throat. 



INFANT FEEDING 



101 



The milk from cows of different breeds contains the same 
ingredients, but in different proportions, as shown by the fol- 
lowing table, the results of quantitative analyses :* 



Fat 

Sugar 

Proteid 

Mineral matter 



DURHAM 

OR 
SHORT- 
HORN. 



4.04 
4.34 
4.17 
0.73 



4.09 
4.32 
4.04 
0.73 



AYR- 
SHIRE. 


HOLSTEIN 

FRESIAN. 


JERSEY. 


BROWN 
SWISS. 


3.89 


3.2 


5.22 


4.0 


4.41 


4.33 


4.84 


4.30 


4.01 


3.99 


3.58 


4.00 


0.73 


0.74 


0.73 


0.76 



COMMON 

NATIVE 



3.69 
4.35 
4.09 
0.76 



Leachf gives the following analyses showing the composition 
of milk of the human and a number of different animals : 



H J [ KIND 
M ^ OF MILK. 

Z 


SPECIFIC 
GRAVITY. 


WATER. 


CASEIN. 


ALBU- 
MIN. 


TOTAL 
PRO- 

TEIDS. 


FAT. 


SUGAR, j 


800 


Cow's milk: 














1 




Minimum . . 


1.0264 


80.32 


1.79 


0.25 


2.07 


1.67 


2.11 0.35 




Maximum . . 


1.0370 


90.32 


6.29 


1.44 


6.40 


6.47 


6.12 


1.21 




Mean 


1.0315 


87.27 


3.02 


0.53 


3.55 


3.64 


4.88 


0.71 


200 Human milk: 
















Minimum . . 


1.027 


81.09 


0.18 


0.32 


0.69 


1.43 


3.88 0.12 




Maximum . . 


1.032 


91.40 


1.96 


2.36 


4.70 


6.83 


8.34 1 1.90 




Mean 


— 


87.41 


1.03 


1.26 


2.29 


3.78 


6.21 1 0.31 


200 Goat's milk: 


















Minimum . . 


1.0280 


82.02 


2.44 


0.78 


— 


3.10 


3.26 0.39 




Maximum . . 


1.0360 


90.16 


3.94 


2.01 


— 


7.55 


5.77 1.06 




Mean 


1.0305 


85.71 


3.20 


1.09 


4.29 


4.78 


4.46 0.76 


32 


Ewe's milk:. 


















Minimum . . 


1.0298 


74.47 


3.59 


0.83 


— 


2.81 


2.76 0.13 




Maximum . . 


1.0385 


87.02 


5.69 


1.77 


— 


9.80 


7.95 \ 1.72 




Mean 


1.0341 


80.82 


4.97 


1.55 


6.52 


6.86 


4.91 


0.89 


47 


Mare's milk: 




















Mean 


1.0347 


90.78 


1.24 


0.75 


1.99 


1.21 


5.67 


0.35 


5 


Ass's milk: 




















Mean 


1.036 


89.64 


0.67 


1.55 


2.22 


1.64 


5.99 


0.51 



* Winslow from Gordon's Tables. 

t Hygienic Laboratory Bulletin No. 41. Marine Hospital Service. 



102 THE DISEASES OF CHILDREN 

On the proteid the body must depend for its growth and 
development, furnishing the material for repair of waste going 
on in the tissues as well as for its growth. • 

Allen* has suggested the term proteid quotient to represent 
the amount of proteid in quantity per pound per day needed 
by the child for its nourishment. He estimates this as 0.04 to 
0.045 of an ounce for each pound of the baby's weight, and 
gives the following working figures: If the milk contains 3.5 
to 4 per cent of proteid, it will be necessary to give 1 to 1.5 
ounces of milk to the pound. 

Proteids. Van Slykef and others have made investigations 
of the chemistry of milk which have been of great value. 

Our knowledge regarding the nitrogen compounds of mill^ 
has been very indefinite, especially with reference to their 
nomenclature. Some have named as many as seven compounds, 
but those most frequently described are casein (caseinogen or 
milk casein), lactalbumin and lactoglobulin. 

The most important of these is the milJc casein which is found 
in combination as calcium casein, and is that portion of milk 
which coagulates in sour milk or as the result of acid or rennet 
precipitation. 

All the elements necessary for nutrition are present in casein, 
namely, carbon, hydrogen, nitrogen, sulphur and phosphorus. 

Van Slyke and Hart:}: have studied the action of acids, alka- 
lies, heat and rennet on calcium casein. They foimd that with 
dilute acid there is a combination of the acid and the calcium, 
and the casein is set free. On the addition of further acid the 
casein molecule combined directly with the acid, forming a 
salt of the acid. The casein and the casein salts of acids are 
insoluble, the coagulum being casein lactate. The casein and 
casein salts dissolve in excess of acid. 

Dilute alkaline solutions, such as the carbonates of sodium, 

* Journal American Medical Association, November 14, 1908. 
t Archives of Pediatrics, July, 1905. 
t Archives of Pediatrics, July 1905, 



INFANT FEEDING 103 

potassium and ammonium react with free casein or its salts with 
acids, and form compounds that are easily soluble in water. 

Heat alone at the boiling point of water does not coagulate 
casein in milk. The skin which forms on milk heated above 
140° F. is due to the calcium casein. 

The most characteristic action of any is that of rennet on 
milk. Calcium paracasein is coagulated, the change being a 
physical one only. To obtain prompt action of rennet the milk 
must net be alkaline ; it must not be diluted with water ; must 
not be heated over 106° or 108°. The rennet and the milk must 
be fresh, and the milk should not be boiled. 

In case of herd milk containing 3.00 to 4.50 per cent of fat. 
Van Slyke* has suggested the following formula for calculating 
the amount of casein: 

(F-3) X 0.4 X 2.1 = per cent of casein in the milk. 

F. in the equation, equals the number representing the percentage of fat 
in the milk. 

Lactalhumin is not acted on by rennet, is not coagulated by 
acids at ordinary temperature, and is coagulated by heat above 
160° F. The ratio of calcium casein to lactalhumin is given 
as 3.6 to 1. 

Ladoglohulin is present in very small quantities in milk. 

Van Slyke gives the following figiires to serve as a guide to 
approximately figure the amount of casein and albumin in milk, 
the fat content being known : 

Per cent of fat in Per cent of casein 

normal milk and albumin 

3.0 2.90 

3.5 3.10 

4.0 3.30 

4.5 3.50 

5.0 3.65 

5.5 3.80 

6.0 3.95 

* New York Medical Journal, May 30, 1908. 



104 



THE DISEASES OF CHILRDEN 



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THE DISEASES OF CHILDREN 105 

Carbohydrates occur in milk in the form of milk sugar or 
lactose (C12H22O11H2O). The souring of milk occurs as the 
result of the action upon the lactose by the lactic acid bacteria. 
If the milk is kept cold these bacteria will not propagate readily. 

The fat content of milk is found in homogeneous emulsion, 
composed of small droplets or globules fairly similar in size. 
The chief fats contained in the fat mixture of milk are olein, 
palmitin and stearin. The fat readily separates from the 
remainder of the milk, forming, on standing, a distinct deeper- 
colored layer above. The fat can be artificially separated by 
means of a centrifugal machine called the "separator." It has 
been claimed by some authorities that separated cream could 
not be reunited with the fat-free milk in the homogeneous mix- 
ture as before separation, but this has not been entirely proven. 

The inorganic salts contained in the milk in solution consist 
chiefly of lime, potash, sodium. These can be separated by 
incineration, and are referred to as the ash. 

The tables of Yan Slyke and Babcock on preceding page 
show the quantities of these substances just enumerated, in cow's 
milk. 

Score Cards. The Bureau of Animal Industry, Department 
of Agriculture of the Government, has suggested a method of 
scoring dairies, herds and milk, and samples of these are here 
reproduced : 

(United States Department of Agriculture, Bureau of Animal Industry, Dairy 

Division) 

Sanitary Inspection of Dairies 

Owner or lessee of farm 

Town State 

Total No. of cows No. milking Quarts of milk produced 

daily 

Is product sold at wholesale or retail? 

If shipped to dealer give name and address 

Permit No Date of inspection 190 . . 



106 



THE DISEASES OF CHILDREN 





SCORE. 


REMABKS. 




Perfect. 


Allowed. 




Cows. 

Condition (2) 


5 
5-20 

5 
5 






Health (8) 






Cleanliness 






Water supply . .... 






Stables. 

Construction 






Cleanliness 






Light . . 


5 






Ventilation (4) 


]^ 






Cubic space per cow (3) . . 






Removal of manure (2) . . . \q oc 

Stable yard (1) / '^ "^^ 

Milk House. 

Construction (2) \ 

Equipment (3) ( 
















Cleanliness 


5 






Care and cleanliness of 
utensils 


5 
5-20 

5 
10-15 

)-» 

5 






Water supply (Temp. °F.) . 
Milkers and Milking. 

Health of attendants 










Cleanliness of milking 

Handling the Milk. 

Prompt and efficient cool- 
ina" 












(Temperature of milk °F) . 
Storing at a low tempera- 
ture 










Protection during trans- 
portation 














100 













Sanitary conditions are: Excellent Good Fair Poor, 

Suggestions by inspector 

Signed 

INSPECTOR. 



Sanitary inspection of dairies {reverse side). 



INFANT FEEDING 107 

DIRECTIONS FOR SCORING. 

Cows. Perfect score. 

Condition and healthfulness : Deduct 2 points if in poor flesh, and 8 

points if not tuberculin-tested 10 

Cleanliness: Clean, 5; good, 4; fair, 2; bad, 5 

Water supply: If clean and unpolluted, 5; fair, 3; otherwise, 5 

Stables. 

Construction: For cement floor (a)* in good condition allow 2 points; 

fair, 1; poor, 0; wood floor (b) or other material in good condition, 1; 

fair, J; poor, 0; good tie (c), 1 ; good manger (d), 1 ; box stall (e), 1 . . . 5 
Cleanliness: If thoroughly clean, including floor (a), windows (b), and 

ceiHngs (c), 5; good, 4; medium, 3; fair, 2; poor, 1 ; bad, 5 

Light: Four square feet of glass per cow, 5; 1 point off for each 20 per 

cent less than 4 square feet per cow 5 

Ventilation: Good ventilating system, 4 ; fair, 3 ; poor, 2 ; bad 4 

Cubic space per cow: If 500 cubic feet or over per cow, 3; less than 500 

and over 400, 2 ; less than 400 and over 300, 1 ; less than 300, 3 

Removal of manure: Hauled to field daily, 2; removed at least 30 feet 

from stable, 1 ; otherwise, 2 

Stable yard: In good condition (a), ^; well drained (b) i; otherwise, . . . 1 

Milk House. 

Construction: Tight, sound floor, and not connected with any other 
building (a), well Hghted (b), well ventilated (c), 2; (d) if connected 
with another building under good conditions, 1 ; otherwise, 0; (e) if no 
milk house, 2 

Equipment: Hot water for cleaning utensils (a), 1; cooler (b) 1; proper 

pails (c) and strainers (d) used for no other purposes, 1 3 

Cleanliness: Interior clean, 5; good condition, 4; medium, 3; fair, 2; 

poor, 1 ; bad, 5 

Care and cleanliness of utensils: Clean (a), 3; kept in milk house or suit- 
able outside rack (b), 2 ; otherwise, 5 

Water supply: If pure and clean running water, 5; pure and clean still 

water, 3 ; otherwise, 5 

Milking. 

Attendants: Healthy 5 

Cleanliness of milking: Clean milking suits, milking with clean dry 
hands, and attention to cleanHness of udder and teats while milking, 
10; no special suits, but otherwise clean (a), 7; deduct 4 points for 
uncleanly teats (b) and udder (c) and 3 points for uncleanly hands (d) . 10 

* The letters a, b, c, etc., should be entered on score card to show condition o^ 
dairy and when so entered should always indicate a deficiency. 



108 THE DISEASES OF CHILDREN 

Handling the Milk. 

Prompt and efficient cooling: If prompt (a), 5; efficient (b), if 50° F. or 

under, 5; over 50° and not over 55,° 4; over 55° and not over 60°, 3; 

over 60,° 0; if neither prompt nor efficient, 10 

Storing allow temperature: If 50° F. or under, 5; over 50° and not over 

55°, 4; over 55° and not over 60°, 3; over 60°, 5 

Protection during transportation to market: If thoroughly protected 

(iced), 5; good protection, 4; partly protected, 2; otherwise, 5 

100 

SCORE. 

If total score is 90 or above and each division 85 per cent perfect or over, the 
dairy is Excellent (entitled to registry) . 

If total score is 80 or above and each division 75 per cent perfect or over, the 
dairy is Good. 

If total score is 70 or above and each division 65 per cent perfect or over, the 
dairy is Fair. 

If total score is below 70 and any division is below 65 per cent perfect, the 
dairy is Poor. 

Care of Milk in the Home. But little care is taken of milk 
in the home of the consumer. Many homes do not have ice 
either in winter or summer and it is entirely impossible to keep 
milk sweet in summer without ice. 

The average time for delivery of milk in the city is from 4.30 
a. m. to 6 a. m. It is left upon the door step or shelf by the 
kitchen door, frequently in summer in the sun, from the time 
it rises until the servants arrive, when the bottles may or may 
not be put on ice at once. Among the poorer classes the milk- 
man rings a bell from his wagon and the customer comes out 
with an open bucket and the milk is drawn from a can which 
has been hauled around the city, in the sun, and without a 
protecting cover, this milk having never been aerated or cooled. 

Milk should not be kept in uncovered vessels or in a refrig- 
erator with vegetables, especially those which give off an odor. 

Among the well-to-do the use of a thermal bottle, an appliance 
for keeping hot things hot and cold things cold, has been sug- 
gested as a labor saver to keep the baby's milk warm at night. 
By keeping milk warm for several hours at a temperature of 



INFANT i'EEDiNG l09 

95° to 100° bacterial growth is very rapid and the milk entirely 
unfit for use. The sale of these bottles for such purposes should 
be prohibited by law. 

Recently a breast-fed baby seven months old, under my obser- 
vation, had been stationary in weight for several weeks, and the 
last week had lost in weight. It was decided to supplement 
the breast feeding by two bottles of modified milk a day. This 
was done, ^^'ith a slight gain in weight but a report of thin 
green stools. Inquiry developed the fact that one feeding at 
night and the first morning feeding were prepared and kept 
warm in the ""thermos" bottle. I had some milk prepared as 
usual the next night and the bottle was not opened until the 
next morning, when some of it was plated, and as a control, 
some of the certified milk delivered the same day and from 
which the sample in the thermos was prepared, also plated. 

The certified milk showed a count of 3400 bacteria per cubic 
centimeter, and the milk in the thermos bottle 1,400,000. The 
child improved at once upon withdrawal of the thermos bottle. 

MORBIDITY A^D MORTALITY STATISTICS AS IN"FLUEK"CED 



It has been estimated that 23 gallons of milk are purchased 
for each person in the United States each year. This A^ery great 
consumption of one commodity must have some influence on the 
population, for good or bad. As children under one year of 
age are the chief users of milk, it must be to statistics we must 
look for an answer to the question : Does milk have any influ- 
ence upon mortality statistics ? 

The United States Census Office reports a population of 
33,757,811. There were 545,533 deaths of all ages and 105,553 
deaths in infants under one year of age. 

Diarrhea and enteritis caused the death of 39,399 infants 
in their first year of life. These figures show a large proportion 

*Eager, Bulletin 14 Hygienic Laboratory, 



IID TtiE DiSilASES OF CaiLDREN 

of the total deaths are in infants under one year of age, and 
a large proportion of these deaths are due to digestive disorders. 
Eager points out that a child consumes 500 quarts of milk 
during its first year, and practically to the exclusion of other 
articles of diet, hence it is safe to conclude that milk is the 
cause of the digestive disturbances which result fatally. It 
is shown also that the mortality in artificially-fed children is 
far greater than in children nursed at the breast. Kewsholme* 
states that, taking the whole first year of life, the number of 
deaths from epidemic diarrhea among breast-fed babies is not 
more than one-tenth the number among artificially-fed infants. 

Epidemics and tuberculosis from a milk source have already 
been referred to. It can readily be inferred that an exhaustive 
study of the milk question as it relates to infant mortality is 
amply justified. 

Sterilization and Pasteurization. Milk brought to the tem- 
perature of 212° F. for 15 minutes is sterilized; when brought 
to 167° F. to 170° F. for 20 minutes it is Pasteurized, the dif- 
ference being entirely the amount of the heat used. Sohxlet, 
in 1886, advised the heating of milk for infant feeding and 
described an apparatus for carrying this out in the home. 

When it is impossible to obtain a milk for infant feeding 
which is known to be clean and cold, or the milk contains a 
quantity of sediment, and sours easily, it is decidedly best to 
submit it before feeding to sterilization or Pasteurization. Pas- 
teurized milk means ^'heated milk,'' and does not necessarily 
mean ^'clean, good or pure milk." 

Both of these processes destroy bacteria, but do not entirely 
destroy their spores. The germs most frequently found in 
milk are the tubercle bacillus, typhoid bacillus, Klebs-LoefEer 
bacillus, the pyogenic cocci and the virus of foot and mouth 
disease of cattle. These are all killed at even a lower tempera- 
ture than 167° if maintained long enough. 

* Loc. cit. 



INFANT FEEDING 



111 



The chief difficulty in wholesale Pasteurization of milk is its 
being heated in bulk and put in unsterilized containers, either 
bottles or cans. To be entirely effective it should be first bot- 
tled, under as strictly cleanly auspices as possible, then Pasteur- 
ized, cooled immediately, and kept cold until consumed. Unfor- 
tunately the Pasteurization or sterilization of milk lulls one 
into a false feeling of security in regard to it. The general 
belief is that the milk so treated will keep indefinitely and 
without ice, whereas if such a sample of Pasteurized milk is 




FIG. 27. 



FOR PASTEURIZING USB PERFORATED TOP WITHOUT OUTER COVER- 
ING; FOR STERILIZING USE BOTH COVERS. 



plated it will be found to contain many thousand bacteria. It 
has been suggested by the E'ew York City Milk Committee's 
report to the Mayor, that when Pasteurized milk is found to 
contain 50,000 bacteria to the cubic centimeter it should be 
destroyed. 

The result of a number of counts made of a commercially- 
Pasteurized milk in Louisville showed an average of 200,000 
bacteria per cubic centimeter. 

Effect of Heat. Owing to the lactic acid bacteria being de- 
stroyed by heat, milk so treated does not sour, but slowly putre- 



112 THE DISEASES OF CHILDREN 

fies. The growth of the putrefying bacteria in raw milk is 
inhibited by the lactic acid bacteria. The effect of heat upon 
milk depends upon the degree of heat, but it so changes the 
proteid that it is difficult to digest by the infant stomach. It 
to some extent coagulates the albumin and renders the milk 
less coagulable by rennet. The exact change which takes place 
is not known, but clinical evidence abundantly proves that 
Pasteurized and sterilized milk do not meet the needs of infant 
nutrition, as rickets and scurvy, both nutritional disorders, occur 
where this milk is exclusively fed. 

Care of Bottles and Nipples. Definite and positive directions 
must be given the mother and the nurse, in her presence, as to 
the care of the bottles and nipples, and a bottle should be 
selected which is most easy to clean. The ITygeia nursing 
bottle has a wide mouth and a large rubber nipple, both of 
which are very easily cleaned and sterilized. The Arnold 
Pasteurizing bottle is difficult to clean because of the narrow 
opening, it being necessary to use a brush in washing. The 
same objection obtains in the Whitehall-Tatum bottle, which 
has a wide, flaring base. 

'New bottles can be annealed by placing them in a vessel of 
cold water, bringing it to a boil, allowing the bottles to remain 
in the water till cold. They crack less readily when so treated. 

If more milk has been prepared than the baby will take at 
a nursing, when the child has finished, the bottle should at once 
be emptied, rinsed with cold water, then with hot, and filled 
with soda solution, which is allowed to remain in it until the 
milk is prepared the following day for the next 24 hours. The 
bottles are then partly filled with soap and water, a tablespoon- 
ful of bird gravel is poured in and the bottles each thoroughly 
shaken, this doing away with the necessity for a brush. They 
are then rinsed and boiled when they are then ready for use. 
They should be kept standing bottom up. 

Enough nipples should be at hand to use a different one for 
each feeding. After a feeding they are washed, turned inside 



INFANT FEEDING 113 

out and allowed to remain in a soda or boracic acid solution 
and boiled with the bottles the following day. Under no cir- 
cumstances should a. long-tube nursing bottle ever be used. It 
is absolutely impossible to cleanse the tube^ and it is a constant 
source of infection. 

The aperture in a nipple should only be large enough to allow 
milk to escape from it, with the bottle inverted, in drops in 
quick succession. If it drops very slowly the opening is too 
small, and should be enlarged very little by the point of a hot 
needle. If the milk runs in a fine stream the opening is too 
large and the nipple should be discarded. 

The bottle is stood in a cup of hot water until the milk is 
about 90° F. The temperature of the milk can be ascertained 
by allowing a few drops to trickle on the back of the liand or 
wrist. The practice of some nurses of drawing a few drops 
from the nipple with the mouth to learn the temperature of the 
milk cannot be too strongly condemned. 

Modified Milk or Percentage System of Feeding. Because of 
the marked difference between the amount of proteids in cow's 




FIG. 28. BOTTLE SHOWING CREAM LINE. 

milk and mother's milk, cow's milk must be so altered as to 
change its fat, sugar and proteid content that it will, as nearly 
as possible, correspond with that of mother's milk. This may 



114 



THE DISEASES OF CHILDREN 



be done in several ways, first by using a definite percentage, 
centrifugal cream in connection with skim milk and a diluent, 
and the addition of sugar of milk in order to bring the carbo- 
hydrate up to the proper amount. Second, by diluting top 
milk, which is a specified number of ounces from the top of a 
quart bottle of milk which has stood four hours in order to 
allow the cream to rise. Third, by dilution of whole milk. 

The ideal method of milk modification is by means of the 
milk laboratory where a physician's prescription for a definite 
amount of the various ingredients of milk can be written upon 
a blank, and this filled at the laboratory as a prescription for 
medicine is in a drug store. The best example of this is the 
Walker-Gordon laboratory, which has established branches in 
many of the largest cities of the United States. The following 
is a prescription blank which is used in connection with one 
of these laboratories : 



Fat 

Milk-Sugar. . 
Albuminoids 
Mineral Matter 
Total Solids 
Water .... 




Number of feedings 

Amount of each feeding , 

Alkalinity 

Heat at 



per cent 

°Y. 



Infant's age . . . , 
Infant's weight. 



Order . 
Date . 



190 



Signature . 



The following is the latest modified milk prescription card 
suggested by Dr. Rotch: 



INFANT FEEDING 



115 



NEW PRESCRIPTION CARD SUGGESTED BY DR. ROTCH FOR LABORATORY USE. 



EXPLANATORY. 



(a) Gravity cream will be 
used, instead of cen 
trifugal if ordered. 

(6) The maximum 
amount of starch pos 
sible in any prescrip 
tion when used as a 
nutrient is 1.30 per 
cent. It requires 
0.75 per cent starch 
to make the precipi- 
tated casein finer. 

(c) One hour completely 
dextrinizes starch. 

{d) In case physicians 
do not wish to subdi- 
vide the proteids, the 
words "Whey" and 
"Casein" may be 
erased. 

(e) It requires 0.20 per 
cent of the milk and 
cream used to faciH- 
tate the digestion of 
the proteids, i.e., the 
formation of a soft 
curd; 0.40 per cent 
to prevent the action 
of rennet, i.e., the 
formation of a tough 
curd. 

(/) Twenty minutes ren- 
ders the mixture de- 
cidedly bitter. 



(a) Fats 



(6) Carbohydrates 



' Lactose (milk sugar) 
Maltose (malt sugar) 
Sucrose (cane sugar) 
Dextrose (grape su- 
gar) 

l Starch (b) 



(c) Dextrinize 



(d) Proteids 



/ Whey. 
\ Casein 



(e) Sodium Citrate. 



(/) Peptonize 



116 



THE DISEASES OF CHILDREN 



EXPLANATORY. 



PER CENT. 



Per 



(g) It requires 20 per 
cent of the milk and 
cream used in modi-^^^ ^ime water 
fying to facilitate the; 
digestion of the pro- 
teids. 50 per cent of 
the amount of milk 
and cream used sus- 
pends all action on 
the proteids in the 
stomach. 5 per cent 
of the total mixture 
gives a mildly alka- 
line food. 



(h) It requires 0.68 per 

cent of the milk and , ^ _ -r^'. , 

J • J- (h) Sodium Bicarb, 

cream used m modi-p '' 

fying to facilitate the 
digestion of the pro- 
teids. 1.70 per cent 
of the amount of milk 
and cream used sus- 
pends all action on 
the proteids in the 
stomach. 0.17 per 
cent of the total mix- 
ture gives a mildly al- 
kaUne food. 



{i) Percentage figures re- 
present the per cent 
of lactic acid attained 

when the food is re-(i) Lactic Acid Bacillus 
moved from the ther- 
mostat. When the 
lactic acid bacillus is 
used to faciUtate the 
digestion of the pro- 
teids, the percentage 
called for represents 
the final acidity, as 
the process is stopped 
by heat at this point. 



cent of milk andi 

J cream 

i Per cent of total mix- 
ture 



Per cent of milk and 
cream 

Per cent of total mix-; 
ture 



(1) To facilitate 
digestion of pro- 
teids. 

(2) To inhibit 
the saprophy- 
tes of fermenta- 
tion. 



INFANT FEEDING 117 



EXPLANATOKY. PERCENT. 



When the lactic acid 

bacillus is used to in- When the lactic acid bacillus is not called 
hibit the growth of for in the prescription, heat at. . . .°F. 

saprophytes,theacid- Number of feedings 

ity may subsequently 

increase to a variable Amount at each feeding oz. 

degree, as the bacilh 
are left alive. 0.25 
per cent lactic acid 
just curdles milk. 
0.50 per cent gives 
thick curdled milk. 
0.75 per cent sep- 
arates the milk into 
curds and whey. I 



A modifying laboratory has been in operation in connection 
with the experiment station of the Kentucky Agriculture Col- 
lege of Lexington, Ky., for several years, and in connection with 
the distributing plant of certified milk in Louisville, operated 
by the Babies' j\Iilk Fund Association. 

To obtain a proper conception of milk modification it is posi- 
tively necessary for one to think of a milk mixture as presenting 
a given percentage of the principal ingredients of milk, namely, 
fat, sugar and proteid, and not of how many ounces it takes 
to make a certain solution or how many times a given quantity 
of milk is to be diluted. One must think in percentages and not 
in ounces. He must remember that the basis of all prescription 
modification is the average analysis of mother's milk and cow's 
milk. 

Dr. T. M. Eotch of Boston first suggested the establishment 
of milk laboratories, and to him and the Messrs. Walker and 
Gordon are due the developments along this line. 

The home modification may be accomplished in a various 
number of ways, some more or less complicated, all, however, 
having the same end in view, that of combining a cream, milk 



118 THE DISEASES OF CHILDREN 

sugar and diluent in such proportions that when analyzed it 
will show a result similar to an analysis of mother's milk. 

Before any prescription for modified milk is given, the milk 
to be used should be examined for the amount of fat content-, 
the proteid in practically all grades of milk being close to 4 
per cent. 

In almost any community can be found a Babcock milk tester, 
a centrifugal apparatus for the estimation of butter fat in mill^. 
In the graduated bottle of the tester is poured 16.5 cc. of milk, 
to this is slowly added 17.5 cc. of commercial sulphuric acid 
(specific gravity of 1.82), the bottle being gently agitated as 
it is poured in. The milk is curdled, but agitation dissolves 
the curds. Hot water is then added as far as the beginning of 
the tube end of the bottle. It is then placed in the machine 
and revolved, the number of revolutions to be employed per 
minute being marked on the cover of the tester. More water 
is added, half way of the tube, and centrifugated again for two 
minutes. Water is again added to the line indicated on the 
scale and centrifugated for two minutes. The fat has completely 
separated now and occupies the top of the column. This is read, 
the highest and lowest parts of the column of fat marking the 
limits of the fat percentage. 

A very rich milk is not often found in cities. If an analysis 
is not possible, average milk may be considered to contain 4 
per cent of fat, 4 per cent of sugar and 4 per cent proteid. 

An average milk, if allowed to stand for four hours in a quart 
bottle on ice, will yield in its top 20 ounces 6 per cent of fat; 
the top 16 ounces 8 per cent fat; the top 9 ounces 12 per cent 
fat; the top 6 ounces 17 per <?ent, and the top 5 ounces 20 per 
cent of fat, and by diluting these top milks almost any per- 
centage of fat, proteid and sugar can be obtained. It should 
be remembered, however, that the proteid in a 16-ounce top milk 
is the same as in whole milk, viz., 4 per cent. The chief thing 
to remember, then, is that the top 16 ounces contain 8 per cent 
fat and 4 per cent proteid, and the top 9 ounces 12 per cent fat 



INFANT FEEDING. 119 

and 4 per cent proteid. The proteid content can be increased 
by adding skim milk or whey. The carbohydrate content is 
increased by the addition of sugar of milk. The proteid content 
of the milk may be modified by the addition of lime water or 
carbonate of potassium. These alkaline agents limit the rennet 
action on the milk and smaller curds are formed. 

The whole character of the milk may be changed by pep- 
tonizing, which prepares the casein for absorption and neutral- 
izes the acid of the stomach. 

If the top-milk method of modification is used the required 
number of ounces are dipped from a quart bottle by means of 
the Chapin cream dipper, the milk having previously stood for 
at least four hours on ice. 

By diluting top 16-ounce milk twice, that is 1 part top milk 
and 1 part diluent, a formula is obtained of fat 4 per cent, 
sugar 2 per cent, proteid 2 per cent. By diluting top 9-ounce 
milk four times, 3 parts diluent and 1 part of milk, the result 
would give a mixture analyzing 3 per cent fat, 1 per cent sugar, 
1 per cent proteid. 

Thus a number of formulae can be worked out as follows : 
Fat 4 per cent 

Sugar 7 per cent 

Proteid 2 per cent 



Dilute 

■ 2)8% 


16 ounces top milk 1 
fat. 4% sugar, 


twice. 

4% proteid. 


4% 


fat, 


2% sugar, 


2% proteid. 

Ounces. 
10 



Top 16 ounces from quart, 

Lime water 2 

Milk sugar 1^ 

Water enough to make 20 ounces. 

Fat 3 per cent 



Sugar 6 per cent. . 
Proteid 1 per cent 



Dilute top 9 ounces milk 4 times. 



4)12% fat, 4% sugar. 4% proteid. 

3% fat, 1% sugar, 1% proteid. 

Ounces. 

Top 12 ounces from quart 6| 

Lime water 2 

Milk sugar 1 

Water enough to make 20 oimces. 



120 THE DISEASES OF CHILDREN 

Fat 1 . 50 per cent ] j^.j^^^ ^^^ ^ ^^^^^^ ^.^^ g ^.^^^^ 

Sugar 5 per cent \^^ 12% fat, 4% sugar, 4% proteid. 



Proteid . 50% 1-50% fat, . 50% sugar, . 50% proteid. 

Ounces. 

Top 12 ounces milk 2^ 

Lime water 2 

Milk sugar 1 

Water enough to make 20 ounces. 

^ Dilute top 16 ounces milk 4 times. 

Sugar 6 per cent | 4) 8% fat, 4% sugar, 4% proteid. 

Proteid 1% J 2% ^^*' 1% ^^^Sar, 1% proteid. 

Ounces. 

Top 16 ounces milk 5 

Lime water 2 

Milk sugar 1 

Water enough to make 20 ounces. 

Sugar. By adding 1 ounce of milk sugar, a little less of 
cane sugar, to 20 ounces of the solution the sugar content is 
brought to 6 per cent. Three level tablespoonfuls of milk sugar 
equals 1 ounce in weight, or 2 level tablespoonfuls of can sugar. 

Additional formulse can be found in the appendix. 

Condensed Milk. This milk is unfit for long-continued feed- 
ing because of its large carbohydrate content and small fat 
content. It is made by evaporating a sterilized cow's milk in 
large vacuum pans to about one-fourth its volume, after which 
is added about an equal amount of cane sugar which acts as a 
preservative. The unsweetened condensed milk and cream will 
quickly spoil if the can is left open. The following is an analy- 
sis of condensed milk. 

EAGLE BRAND.* Per cent. 

Fat 8.8 

Sugar 52.2 

Total proteid 9.3 

Total solids 72 .2 

Ash 1.9 

Water 27.8 

* Sondern: in Kerley Treatment Diseases of Children 



INFANT FEEDING 



121 



The following anaylses are given by Chapin, from the United 
States Department of Agriculture: 



^ K PS a 

£0 o !^ o 

o S « 

O O Oh 



CONDENSED MILK 
PER CENT. 









(s • 

"^ ? & 

0, H Z 

W H ^ 

t^ ^ ? 

5 ^ Ph 



gs 


g2. 


^^^ 


^gg 






0.70 


0.84 


0.60 


0.72 


4.43 


5.32 


0.15 


0.18 


94.12 


92.94 



goo 
<i ^ z 



0.60 
0.52 I 
3.80 i 



4.00 Fat 8.44j 0.53 

3.50 jProteid 7.23 0.45 

5.00 i_, /cane, 41.52 \ ! 3.33 
i^^g^^lmilk, 11.69 /--^^^li 

0.70 jsalts 1.801 0.11 0.13 

86.80 Water 28.14! 95.58 94.95 



1.05 
0.90 
6.65 

0.22 
91.18 



Owing to the thickness of condensed milk, and the varying 
sizes of spoons, it is difficult to dilute condensed milk accurately. 
If a teaspoonful of condensed milk is removed from the can, 
without allow^ing it to drip until the spoon is level full, it will 
contain fully a teaspoonful and a half. Hence, when measuring 
condensed milk, each spoonful should be allow^ed to drain until 
it does not drip, and its bottom scraped off on the can before 
adding the water. The same spoon should be used to measure 
the water also. 

The reasons for its popularity among the poor is that it is 
cheap, is easily prepared, and does not spoil as quickly as 
ordinary milk. 

From the analyses given it can readily be seen that the fat 
percentage in any dilution, even 1 to 8, is much too small, and 
the mixture in this strength, 1 to 8, is sickening sweet. 

As a substitute feeding in difficult feeding cases a weak dilu- 
tion of condensed milk is of great value, but it does only as a 
temporary food. If used for some time the fat content can be 
increased by the addition of a drachm or so of top milk, the 
gradual resumption of cow's milk being attained in this way. 

Kerley has suggested the administration of cod liver oil to 
augment the fat in condensed milk. 



122 THE DISEASES OF CHILDEEN 

Children fed on condensed milk are usually fat, but flabby, 
and have little resistance to acute illness. 

Peptonized Milk. In a milk which has been peptonized the 
proteids have been digested, converted into soluble peptones, 
and this can be accomplished partially or completely. When 
completely peptonized the milk has a bitter taste. When milk 
is used in nutrient enemas it should be completely peptonized, 
as the bowel in this part is not a digesting organ, but an absorb- 
ing one. Peptonizing tubes (Fairchild) contain 5 grains of 
pancreatine and 16 grains of sodium bicarbonate. The contents 
of one of these tubes is dissolved in 4 ounces of water and 
stirred into 1 pint of fresh milk. This is then heated from 
105° to 115° F. for 20 minutes. The process of peptonization 
or digestion can be stopped by placing the vessel on ice or by 
bringing the milk quickly to a boil. If a child is being fed 
upon a modified milk and it is necessary to peptonize it, the 
contents of part of a tube can be added to the bottle before feed- 
ing, and the bottle stood in a vessel of water at a temperature 
of 120° F. and allowed to remain for 20 minutes. It is then 
cooled to the proper temperature for feeding. Peptonized milk 
should never be given over a very long period as it relieves the 
stomach of work which it should be made to do. 

Whey. To prepare whey the milk is heated to a temperature 
of 104° F. and removed from the fire. Two teaspoonfuls of 
essentia pepsin are added and gently stirred for thorough mix- 
ing and the curd allow^ed to form firmly. This is then broken 
up with a fork and strained through a piece of cheese cloth by 
gravity alone. 

In certain difiicult feeding cases, fat-free whey mixtures can 
be used to great advantage. Practically all of the casein has 
been removed, the casein remaining being approximately .35 
per cent. The following analyses from Van Slyke show the 
food value of whey obtained from various grades of milk: 



INFANT FEEDING 



123 



WHEY. 
FROM POOR 

MILK 

CONTAINING 

3 PER CENT FAT 



FROM MEDIUM 

MILK 

CONTAINING 

4' PER CENT FAT. 



FROM RICH 

MILK 

CONTAINING 

5 PER CENT FAT. 



Total soUds 6.87 

Fat 0.28 

Total'proteids .69 

Sugar and ash 5.90 

Water 93.13 



6.96 


7.38 


0.30 


0.30 


0.87 


1.03 


5.79 


6.04 


93.04 


92.62 



When in difficult cases a child has thrived for a time upon 
whey, an increase both in the fat and proteid content can be 
had with an addition very gradually of top milk. 

By boiling the whey before the addition of the top milk the 
rennet ferment remaining in the whey is destroyed, the small 
quantity of proteid contained in the added milk will not be 
curdled, otherwise when the mixture is heated to the proper 
temperature for feeding a slight curdling takes place in the 
milk. 

Southworth* suggests the following method of making whey 
and of whey feeding : 

Method of Making Cream and Whey Mixtures. Secure a quart 
bottle of good average milk upon which the cream has risen. 
Remove with the Chapin dipper the upper 5 ounces of the 
cream layer, which, when mixed, will contain about 20 per cent 
of fat, and preserve this for further use. Pour the remainder 
of the bottle (about 27 ounces) into a double boiler, the lower 
portion of which contains tepid water, and add 1 tablespoonful 
Shinn's liquid rennet, or 1 Hansen's junket tablet, or 1 table- 
spoonful of Wyeth's liquid rennet, or 2 tablespoonful s of essentia 
pepsin CN. F.). Mix thoroughly. Place a chemical thermom- 
eter in the whey and heat slowly up to 155° F. (68° C.) to 
destroy the rennet ferment, which otherwise would clot the 
casein of the cream or top milk when subsequently added to 
the whey. Heated beyond 155° F. the albumin, part of the 



*Carr Pediatrics. 



124 



THE DISEASES OF CHILDREN 



soluble proteids^ will be coagulated and the nutritive value of 
the whey reduced. As soon as a solid curd forms cut this cross- 
wise into small pieces with a table knife to facilitate the escape 
of the whey, and while continuing to heat to 155° F. use the 
flat of the knife blade to assemble and press together the pieces 
of curd. This increases materially the yield of whey, and the 
curd finally contracts with heat and manipulation into a rub- 
bery lump the size of the palm of the hand. Straining through 
a wire strainer now gives 20 ounces or more of moderately 
opaque yellowish whey, upon which but little fat rises on stand- 
ing. Adding to 20 ounces of this whey varying amounts of the 
top 5 ounces of cream (20 per cent fat), previously removed, 
will give us a series of formulae suitable for most purposes where 
cream and whey mixtures are required. By removing and using 
the top 6 ounces (17 per cent fat) or top 7 ounces (15 per 
cent fat), mixtures may be obtained with a lower fat per- 
centage; or by using more of these top milks in the mixture 
the same amount of fat with a larger proportion of casein in 
the proteids. 

WHEY AND CREAM MIXTURES, MADE FROM 20 PER CENT CREAM (TOP FIVE OUNCES 
OF ONE QUART BOTTLE) AND TWENTY OUNCES OF WHEY FORM REMAINDER 
OF BOTTIiE, 





FAT 


SUGAR 


PROTEID 




PER CENT- 


PER CENT- 


PER CENT- 




AGE 


AGE. 


AGE. 


20 oz. whey -1- 1 oz. cream (20 per cent fat) = 


1.00 


5.00 


0.90 


20 oz. whey -t- 1^ oz. cream (20 per cent fat) = 


1.50 


5.00 


1.00 


20 oz. whey + 2 oz. cream (20 per cent fat) = 


2.00 


5.00 


1.10 


20 oz. whey + 2^ oz. cream (20 per cent fat) = 


2.40 


5.00 


1.15 


20 oz. whey + 3 oz. cream (20 per cent fat) = 


2.75 


5.00 


1.20 


20 oz. whey + 3^ oz. cream (20 per cent fat) = 


3.15 


5.00 


1.25 


20 oz. whey + 4 oz. cream (20 per cent fat) = 


3.50 


5.00 


1.30 



Any case in which mild stimulation is desired an addition 
of an ounce of sherry wine to a pint of whey is frequently 
desirable and of benefit. 



INFANT FEEDING. 



125 



Ramogen. Biedert's Cream Mixturej called Ramogen, is a 
preparation which in certain difficult feeding cases is of some 
service as a temporary food. 

Cow's milk can be added to a Ramogen-Avater mixture as 
acute syiaptoms have subsided. The following analyses have 
been given in various dilutions : 





" 


CALORIES 
IN 100 CC. 




PERCEXTAGE OF 


KAMOGEX. 


WATER. 


Proteids. 


Fat. 


Carbohydrate.-^. 




13 


25 


0.52 


1.23 


2.7 




11-12 


26-27 


53- . 56 


1.3-1.36 


2.8-3 




10 


30 


0.63 


1.48 


3.1 




9 


33 


0.7 


1.65 


3.46 




8 


35 


0.77 


1.81 


3.8 




7* 


38 


0.81 


1.93 


4. 




7 


41 


0.87 


2.06 


4.3 




6* 


43 


0.93 


2.19 


4.6 




6 


45 


0.98 


2.31 


4.8 




oh 


50 


1.07 


2.54 


5.3 




5 


54 


1.15 


2.72 


5.7 



The foiloAX'ing analyses is given of Ramogen and whole-milk 
mixtures : 



MIXTURE OF 




PE_RCENTAGE OF 
















Ramogen. Water. 


Milk. 


IN 100 CC. 


Proteids. 


Fat. 


Carbo- 
hydrates. 


1 \2h 


2 


30 


0.92 


1.39 


2.5 


1 12 


3 


33 


1.17 


1.54 


2.8 


1 11 


3i 


35 


1.29 


1.64 


2.88 


1 IH 


4 


37 


1.42 


1.74 . 


3.0 


1 m 


4i 


39 


1.54 


1.83 


3.12. 


1 10 


5 


41 


1.66 


1.92 


3.24 


1 9^ 


-oh 


43 


1.78 


2.01 


3.36 


1 8 


6 


45 


1.92 


2.11 


3.5 


1 8i 


U 


47 


2. 


2.19 


3.6 


1 8 


7 


49 


2.18 


2.34 


3.76 


1 7i 


7i 


51 


2.3 


2.4 


3.9 



126 THE DISEASES OF CHILDREN 

Calorie. A calorie is the amount of heat required to raise 
the temperature of 1 kilogram of water 1° C, which is about 
equivalent to the amount required to raise a pound of water 
4° r., and is used as a unit of measure of food value as ex- 
pressed in terms of heat production. 

Atwater claims that: 

One gram of protein furnishes 4 calories ; 1 pound furnishes 
1920 calories. 

One gram of fat furnishes 8.9 calories; 1 pound furnishes 
4040 calories. 

One gram of carbohydrate furnishes 4 calories; 1 pound 
furnishes 1820 calories. 

It has been suggested by Heubner, Biedert and others that 
during the first year of life a child should receive about 100 
calories per kilo (2^ pounds) of body weight in 24 hours, i. e., 
for every pound of its weight it should receive sufficient food 
to provide 45 calories of energy. During the next three months 
from 40 to 45 calories per pound, decreasing, until at 12 months 
they consume 32 to 35 calories, daily, per pound of body weight. 
The following approximate schedule of infant requirement is 
given by Heubner: 

55 calories for the first week. 
107 calories for 2 to 12 weeks. 
91 calories for 13 to 24 wteks. 
83 calories for 25 to 36 weeks, 
69 calories for 37 to 44 weeks. 

Pierre Budin"^ states that average composition per liter of 
human milk is: 

35 grams of butter. 
74 - 75 grams of lactose or milk sugar. 
12 - 14 grams of proteids of albumenoids. 
2 grams of mineral salts. 

A total of 175 grams of solids. 

He states the most important substance in the maintenance 
of the body heat is butter, as it is the constituent in milk which 

* The Nursling. 



INFANT FEEDING 127 

contains the greatest number of calories. One gram of butter 
yields 9.3 calories, and 96 per cent of the butter in milk is 
utilized by the organism. If the number of calories repre- 
senting the average alimentary ration of an infant, that 53 per 
cent, more than half, come from butter. It is estimated that 
sugar of milk furnishes 29 per cent, and the albuminoids 18 per 
cent of the total calories. 

It has been shown that the energy equivalent of 1 grain of 
fat is 9.1 calories; of 1 gram of carbohydrate 4.1 calories, and 
of 1 gram of proteid 4.1 calories. To calculate the calorimetric 
requirements, determine from the body weight the number of 
calories required. A child often requires 45 calories per pound 
or 450 calories, the first of the equation needed. 

An ounce of whole milk contains 21 calories. 

An ounce of carbohydrate contains 120 calories. 

An ounce of 16 per cent cream contains 54 calories. 

One ounce of skim milk contains 10 calories. 

One ounce of flour or cereal contains 120 calories. 

One ounce of cereal water contains 2 or 3 calories. 

The number of calories in the mixture can be obtained from 
multiplying the number of ounces of the various individual 
ingredients in the mixture by the above fignires and adding the 
results together to find the energy quotient of the mixture. 
Divide the total number of calories by the niimher of pounds 
and multiply this result by 2.2 to get the number of calories 
per kilogram. 

Diluents in Milk Formulae. Because of the fact that the casein 
of cow's milk coagulates in such large masses in the process of 
digestion, it has been suggested that the addition of a cereal de- 
coction will enable the stomach juices to coagulate the casein 
mixture into the smaller flocculi like mother's milk. In order to 
determine the capacity of an infant to digest starch, Kerley 
made a large number of stool examinations which showed con- 
clusively that the majority of infants of any age are able to 
digest starch. He says ''that starch foods may be added with 



128 THE DISEASES OF CHILDREN 

benefit to infant-milk foods in a great majority of cases, and 
that they may be used with benefit as a substitute for these foods 
in illness is established beyond all question, both experimentally 
and clinically." The addition of a dextrinizing agent to any 
of the cereal decoctions is to be recommended, among which may 
be mentioned plain maltine and cereo, the latter made by the 
Cereo Company of Tappan, E'ew York. One teaspoonful of 
cereo to the pint of cereal gruel will completely dextrinize it 
and render it more easy of digestion and absorption. As to 
the use of dextrinizing agents, authorities differ, Koplik not 
advocating their use, except in cases in which it is demonstrated 
that the infant is not taking care of the plain decoction. In 
certain marasmic infants in which the percentage method of 
feeding has failed, Keller's method of dextrinizing gruel may 
be tried. The following description of a malt soup is given 
by Keller, as used at the University Children's Clinic in 
Breslau : 

Three and a half ounces of malt soup extract are added to 
500 cc. of water, or 1 pint, and dissolved. This is solution 'No. 
1. Then suspend 3 ounces (in measure or 2 ounces in weight) 
of wheat flour in 500 cc, 1 pint of milk, so that the solution is 
quite uniform. The milk and flour solution is then strained 
through cheese cloth. The solution of malt extract and that 
of the milk and flour are mixed together, put into a common 
vessel and brought to a boil, being stirred constantly over a slow 
fire. After about 20 minutes of stirring the whole mixture is 
brought to a boil to stop all processes of digestion. The mixture 
is now put up in bottles, each containing about 6 ounces, corked, 
and kept cool. This mixture contains dextrinized cereal and 
malt sugar in addition to the proteids of the milk. Loeflund's 
malt soup extract contains maltose, 57 per cent; dextrine, 12.4 
per cent. Wheat contains 66.8 per cent of starch, 7.5 per cent 
of dextrine, and a small amount of dextrose. By the action of 
the ferments in the malt extracts — principally diastase — the 
starches are converted into sugars. By this method a number 



INFANT FEEDING 129 

of easily-assimilable substances are introduced into the economy. 
The action of these processes on the casein coagulation seems 
favorable to its assimilation. 

This malt soup preparation is recommended in subacute 
enteric catarrh in which milk in simple dilution is not assim- 
ilated. Dr. Keller claims that the acid intoxication which is 
present in marasmic infants yields to the administration of this 
malt soup. He found the food of most value in atrophic infants 
from 6 to Y pounds in weight, and in infants who after the 
twelfth month either refuse to take milk food in any form or 
do not thrive and are stationary in weight. After increasing 
in weight and taking the foods for two or three months, it is 
best to take them off the food gradually and accustom them to a 
modified milk. The chief difficulty in the way of the use of 
this food is its cost. 

In making barley gruel, cereo barley flour, Eobinson's patent 
barley flour or pear barley may be used; 1 level tablespoonful 
of the flour or 2 tablespoonfuls of the pearl barley added to a 
quart of water, and this boiled in double boiler for 15 or 20 
minutes over a hot fire, stirring constantly until the resultant 
liquid is about one-half in quantity. If the pearl barley is 
used, it should first be soaked for a short while and this liquid 
poured off before the boiling is done. The gruel is then strained 
through a fine cloth, the vessel stood in cold waller, and when 
cool enough to taste the dextrinizing agent is added. The dex- 
trinizing agent is not added when the gruel is hot, as its diastatic 
properties are destroyed at a temperature of about 140° T. 

Ladd* has shown that the decoction made by using 2^ ounces 
of either barley or oat flour to a quart of water, cooking for 30 
minutes and adding sufficient water to make 1 quart, yields 
about 3.50 per cent of starch, and is as thick a solution as can 
conveniently be strained. This 3.50 per cent decoction has 
therefore been adopted as the stock solution in the milk lab- 
oratories. 

* Archives of Pediatrics, April, 1908, 



130 THE DISEASES OF CHILDREN 

On this basis the amount of stock cereal decoction to be added 
to a mixture of modified milk to obtain any percentage of starch 
can be calculated by the formula. 

Bj using 3 ounces of the flour to a quart of water, the stock 
solution of cereal gives 4.5 per cent of starch, and if straining 
the solution is dispensed with, higher percentages can be given 
than in the above table, 4.50 being substituted for the denomi- 
nator, 3.50. An ounce of flour by measure is pratically the 
same as by weight. 

Food Formulae. Junket. This is made by coagulating the 
casein of cow's milk by the addition of Fairchild's essence of 
pepsin rennet, or junket tablet or essentia pepsin ^N. F.). One 
teaspoonful of pepsin is gently stirred into a pint of fresh, 
clean cow's milk and the milk brought to a temperature of 
115° F. for about 20 minutes. It is then removed from the 
stove and when a thick curd has formed it is broken up with a 
fork and can be served with or without sugar. One teaspoonful 
of sugar can be added. 

Albumin Water. This is made by adding the white of one 
egg to a pint of cold water, stirring sufiiciently to cause a 
thorough mixture, but not beating the egg as it is mixed. Owing 
to the fact that the albumin water is a good culture medium for 
bacteria, it is not advisable to use this as a substitute feeding 
in acute dyspeptic or diarrheal diseases in children. 

Beef Juice is prepared by flrst cutting a piece of lean beef 
into small cubes and while held upon a fork heated through 
upon a hot plate or pan. The juice is then expressed by means 
of a meat press or lemon squeezer into a warm vessel. It is 
possible to obtain from 4 to 5 ounces of beef juice from a pound 
of steak. Beef juice may be fed plain or in combination with 
barley water after salting to taste. 

Animal Broths. These may be made from beef, chicken, mut- 
ton or veal. A pound of meat cut into small parts is boiled 
for about two hours in a quart of water, enough water being 
added from time to time to keep the resultant liquid at about 



INFANT FEEDING. 131 

1 pint. All of the broths should be strained thoroughly through 
a fine colander and allowed to cool; the fat which rises to the 
surface is then carefully removed. As a temporary food they 
are very good, especially in some of the forms of diarrheal dis- 
eases. They contain very little fat, about 1 per cent of proteid 
and nearly 2 per cent extractives. 

Arrowroot Gruel. This substance has been used as a diluent 
for milk, as it has the same effect in breaking up the casein 
as other cereal decoctions. One teaspoonful of Bermuda arrow- 
root is dissolved in a pint of water, allowing it to cook slowly 
for 20 minutes, stirring constantly, strained and allowed to cool. 

Kumyss is fermented milk, and while sometimes taken by 
older children it is objected to by a majority. Konig* gives 
the following analysis of kumyss : 

Water 90 . 44 

Alcohol 1 .91 

Lactic acid 0.91 

Milk sugar 1 . 77 

Proteid 2.44 

Fat 1 .46 

Ash : 0.142 

Holt recommends the following formula for its home 
manufacture : 

One quart fresh milk, -| ounce sugar, 2 ounces water and 
piece of fresh yeast cake -J inch square, put into wired bottles 
and kept at a temperature of 60° and 75° F. for a week. The 
bottles are shaken five or six times a day and then put on ice. 

Buttermilk. Fat-free buttermilk has been used in difficult 
feeding cases and those convalescent from severe enteric dis- 
turbances with great benefit. Because of the great bacterial 
content of buttermilk from churned milk it has not been con- 
sidered a safe food, but since the introduction of the pure lactic 
acid bacteria in tablet form for the artificial manufacture of 
buttermilk, its use has become more general and the results 
better. 

* Koplik. 



132 THE DISEASES OF CHILDREN 

From a quart bottle of milk the top 12 ounces are removed 
and 12 ounces of water added in which one lactone tablet has 
been dissolved. This is shaken and the bottle kept at a tem- 
perature of 80 degrees until the milk is curdled, when it is put 
on ice and the lactic acid fermentation stopped. This is at first 
given slightly diluted and finally undiluted. Good buttermilk 
contains from 0.5 to 1-J per cent of fat; 2.5 to 3.5 per cent of 
sugar, and about 2.5 per cent of proteid. The calorie value 
of buttermilk averages about 400 calories per liter. 

In certain acute intestinal disorders the following method of 
preparation can be employed: In a liter of buttermilk is dis- 
solved a tablespoonful of flour and 3 tablespoonfuls of cane 
sugar, heat to boiling, stirring constantly, cooled, and again 
twice boiled. 

Oatmeal Jelly. Two tablespoonfuls of oatmeal, rolled oats 
or Quaker oats, or oat-gruel flour, to 1 pint of water boiled 
slowly for three hours, water being added to keep the amount 
at 1 pint. Strain through a colander, allow to cool and keep 
on ice. One tablespoonful, level, of the flour equals ^ ounce. 

Scraped Beef. A thick, lean steak is heated through on a 
hot griddle. With a sharp knife the browned surface is cut off 
and with a knife held at right angles to the meat, the pulp is 
scraped away, made into a meat ball, again heated through 
and fed after salting to taste. 

Percentage Cereal Gruels. The following analysis is given 
by the Cereo Company of gruels made from their specially-pre- 
pared flours. The top of the package has been designed as a 
measure for the flour. Barley, legume (made from beans), 
oats and wheat are utilized for preparation of flours. From 
the accompanying table can be seen the strength of the gruel 
when larger or smaller quantities of flour are used in the water : 



INFANT FEEDING 133 



fi 


i f.i 


^ 


1 1^ 


^. 


1 

si 


-, 


1 1^- 


-ss 


, ss 


-SS 


, ss 


13 <D 


1 , SS 1 


-^S 


i ,2S 


•Jfe 




s^. 


OT3 iH 


s^ 


arbo 
hyd 
per 


■J S3 


illss 


oa 


55-^^ 


oa 


^^^ 


2K 


ou 


Ss"^ a 


■ PM 


6 


P4 


I ^ 


fin 


c;> 


fL, 


o 



I oz. flour to qt. of j 

water 0.12 0.60 0.19 0.53 0.12 0.60 0.10 ' 0.62 

^ oz. flour to qt. of | ! 

water 1.25 1.20 ' 0.39 1.06 0.24 1.20 0.20 1.25 

I oz. flour to qt. of 

water 0.36 1.80 0.58 1.59 0.36 1.80 0.30^1.88 

1 oz. flour to qt. of 

water 0.48 2.40 0.78 2.12 0.48 2.40 0.40 2.50 

2 ozs. flour to qt. of 

water 0.96 4.80 1.56 4.24 0.96 4.80 0.80 5.00 

3 ozs. flour to qt. of ' 

water 1.44 7.20 2. .34 6.36 1.44 7.20 1.20 | 7.50 

4 ozs. flour to qt. of 

water 1.99 9.60 3.12 8.40 1.92 9.60 1.60 10.00 



Symptoms of Disagreement of Milk Feeding. Insufficient quan- 
tity. Child will cry immediately the bottle is empty and will 
suck on its fists. 

Too Much Fat. Vomiting will occur very soon after a 
feeding ; stools more frequent and thin ; presence of lumps of a 
soft material resembling curds. 

Too Much Sugar. Thin, green stools with gas passed with 
each; an excoriation of buttocks frequent. 

Too Much Proteid. Colic; vomiting; curds in actions, fre- 
quently in large numbers, either large or small, with much 
mucus mixed or separate. There may be alternating diarrhea 
and constipation. 

Talbot^ has shown '^that the curds in infants' stools are either 
large curds containing a large per cent of nitrogen and a small 
per cent of soaps ; and small curds containing a low per cent 
of nitrogen and a large per cent of soaps. He concludes these 

* Boston Medical and Surgical Journal, January 7, 1909. 



134 THE DISEASES OF CHILDREN 

large curds are composed of some proteid, probably casein or 
one of its derivatives, which, on coagulating, entangles the milk 
fat in its meshes. The amount of fat in the curds depends on 
the amount of fat in the milk, and as the fat increases it replaces 
the proteid in the curd. The presence of large curds can be 
interpreted — as indicating lack of HCl. ''The small curds* 
are composed mainly of fat, mostly in the form of fatty acids 
and soaps. There is no evidence that they contain casein-like 
material, and they have, like the normal stool, a low percentage 
of nitrogen. They represent the fat in the stool rather than 
protein." 

Difficult Feeding Cases. The above-named symptoms may be 
present successively as the case progresses and each must be 
met by appropriate measures. As before stated, one must not 
attempt to adapt a formula to a certain age. Each child must 
be a law unto itself. A weak formula in all its ingredients must 
first be given, even if the digestion has been entirely normal, 
though it be at the sacrifice of several ounces in the child's 
weight, rather than upset the child's digestion by a strong mix- 
ture, and not be able to get it back on a gaining formula for 
some time. 

The first formula should contain less than 2 per cent of fat 
and less than 1 per cent of proteid, and this may be increased 
daily or every other day until the child appears satisfied and 
evidences a gain in weight. It is the proteid content which will 
cause the most trouble with the majority of difficult cases, though 
fat intolerance is frequently seen. I have had under my care 
one child who, from six months to one year of age, could not 
be gotten up beyond 3 per cent of fat, the prescription upon 
which she thrived best being fat, 3 per cent ; sugar, 6 per cent ; 
proteids, 2 per cent. 

To aid the digestion of the casein, and to assist in its break- 
ing up in small fiocculi, several measures have been advocated. 
Poynton of London suggested the use of citrate of soda in the 

* Boston Medical and Surgical Journal, June 11, 1908. 



INFANT FEEDING 135 

proportion of 1 grain to the ounce of milk. He claims that 
sodium paracasein is formed which is absorbed as a fluid. Cot- 
ton of Chicago has advocated its use also. The soda is not an 
alkali but an alkali is needed for the purpose of assisting in 
breaking up of the curds, and to favor the production of hydro- 
chloric acid, hence the importance of the addition of lime water 
to the formula. Rotch claims the soda decalcifies the casein, it 
is then not affected by rennet forming with the acids of the 
stomach, soft, friable flakes of the buttermilk type. 

The following case is an example of this difficult feeding 
class : Child born after normal labor of short duration ; mother 
primipara, very nervous temperament, anemic ; abundant sup- 
ply of milk at first but gradual failure ; history in child of slight 
jaundice; colic, crying all the time; curds and mucus in move- 
ments; had been taken off of breast milk and given successively 
malted m.ilk, barley water and malted milk, barley water and 
panopepton, albumin water and malted milk, barley water and 
panopepton, albumin water, Ramogen. Five weeks old when I 
saw it first ; constant crying ; tense abdomen ; given 2 teaspoon- 
fuls of olive oil and put on a dextrinized gruel and whey, 
equal parts, 2 oimces every two hours. The first night it slept 
all night, had two movements, well digested. On third day it 
was given a mixture of whey, 2 ounces, and barley water, -J 
an ounce, and was nursed by the mother twice, with a bottle 
after each, when about half quantity was taken. On fourth 
day was put on modified milk fat 1.5 per cent, sugar 6 per 
cent, proteid .8 per cent. Gained 10-J ounces the first week 
and in every way seemed normal. 

The history of this case is a counterpart of a number that 
are seen, and unless the child has developed into an athreptic 
or marasmic state before seen this plan will usually bring good 
results. 

At the first sign of disagreement remove the milk mixture 
and give one of the cereal decoctions ; after a few days try a 
small amount of whey with the cereal; then add milk grad- 



136 THE DISEASES OF CHILDREN 

ually. If cow's milk in this form cannot be assimilated, try 
condensed milk as a temporary food, beginning this with a 
dilution of at least 1 part to 20 or 24. Top milk may very ten- 
tatively be added to the condensed milk and gradually increased, 
and in this way get on to a gaining formula. 

Care of Milk for Journey. One is frequently asked to sug- 
gest a method of preparing milk for a journey. I recently had 
a box fixed for two children starting for Mexico. A wooden 
box was built around an ordinary galvanized delivery tray hold- 
ing 4 quart bottles, a handle and hasp being soldered on. The 
4 quart bottles were surrounded with ice and instructions given 
as to change of ice by car porters en route. Certified milk was 
sent, and word received from travelers at journey's end reported 
milk sweet and unchanged. If a modified milk formula had 
been required for either of these children it could have been 
prepared and placed in nursing bottles or a quart Mason fruit 
jar with screw top, and the bottle shaken before each feeding 
was poured into the nursing bottle. 

Diet After the First Year. Milk should be the basis of a 
child's diet for the first 12 months. Weaning (see page 82) 
should be begun before the twelfth month, and artificial feeding 
be complete, or nearly so, at that time. At 10 or 11 months 
of age one feeding a day can be given of strained oatmeal, 2 or 
3 tablespoonfuls, over which is poured some of the modified 
milk. With the advent of the first six or eight teeth, an occa- 
sional piece of toast or zwieback can be given the child to 
chew on. 

Only one new article of diet should be given at a time, for if 
the child takes two new ones and is upset, unless passed undi- 
gested, the disturbing cause would not be known. 

Eegularity of feeding should be positively insisted upon, and 
the habit of between-meal eating ^ ^stopped before it has begun." 
Nothing but water should be given between meals. The habit 
of continuing night feedings until the second year should never 
be allowed. 



INFANT FEEDING. 137 

While it is a pleasure but few parents Avill deny themselves, 
a young child should not be allowed at the table at the family 
meal times. The temptation to give the child a taste of this 
or that is too great to be resisted. 

Fruit juices should be given before the end of the first year, 
orange being usually most enjoyed. It should not be given too 
close to a milk feeding. After the first year prune juice, if not 
too sweet, can be given. 

The following diet lists are suggested as a guide for feeding 
after the first year: The first feeding in morning and last 
feeding at night are usually milk, and the child at this age 
requires more than can be held in the ordinary bottle, which 
is made to contain 8 ounces. AVhitehall-Tatum Company manu- 
facture a 12-ounce bottle, and at my suggestion the Hygeia 
ITiirsing Bottle Company have begun to manufacture a 12- 
ounce Hygeia bottle, which will be found a great convenience, 
obviating the necessity of preparing two bottles for each feeding. 

From Twelfth to Fifteenth Month. Five meals a day. The 
first meal, 6.30 to 7.30 a. m., 8 or 10 oimces of milk; 10 a. m. : 
Strained oatmeal jelly, 2 or 3 tablespoonfuls with 4 or more 
ounces of milk in addition, or soft-boiled Qgg not oftener than 
three times a week, l^oon : Juice of half an orange. 1 o'clock : 
Scraped beef and bread crumbs, or rolled zwieback or 4 to 6 
ounces of animal broth, with zwieback or Holland rusk. 4 p. m. : 
Bread and milk. 7 p. m. : bottle of milk. 

From Fifteenth to Eighteenth Month. To the above list may 
be added the cooked fruits, as prunes, not too sweet ; the inside 
of a baked apple or apple sauce ; thoroughly cooked-rice ; boiled 
or baked potato ; junket ; finely-minced mutton chop. 

From Eighteenth Month to Third Year. During this period 
other vegetables may be added gradually, as spinach, asparagus 
tips, stewed celery, baked potato, peas, beans, fish, thin, crisp 
bacon, minced chicken or turkey, roast beef, cream, crackers, 
bread and butter. 

Sample diet list from sixteenth to eighteenth month : 



138 THE DISEASES OF CHILDREN 

Breakfast^ 7 a. m. Strained oatmeal, 2 or 3 tablespoonfuls, 
and cream, or barley gruel, and cream with 8 ounces of whole 
milk. 

Second Meal, 10.30 a. m. Milk and stale bread, or cracker, 
rusk or zwieback. 

Third Meal, 1.30 to 2 p. m. Any of the following: Soft- 
boiled egg (water boiled vigorously, removed from stove, and 
egg dropped in for two minutes), with broken toast or zwieback ; 
(b) 8 ounces of animal broth (beef, mutton or chicken) ; (c) 
a teacupful of junket with milk; (d) thoroughly-cooked rice 
and milk. Stewed prunes can be given with this meal. 

Fourth Meal J 5.30 to 6 p. m. Bread and milk. Fruit juices 
are given between meals, as suggested in previous lists. 

To be Avoided. Candy should not be given to children under 
three years of age, and very sparingly after that time. Sweets of 
all kinds cause a tendency to develop a pharyngeal trouble such 
as adenoids, tonsillitis and frequent attacks of ''colds" and 
bronchitis. 

Artificial Foods. The fact that there are upon the market 
almost countless numbers of baby foods is evidence enough that 
none answers the requirements in all cases. These foods may be 
divided into three classes; first, the so-called milk foods to which 
water is added, and those foods in the form of powder which 
have been suggested as modifiers of milk. The latter are added 
to milk for their influence upon the casein. Second, the so- 
called Liebig or malted foods, and third, the farinaceous foods. 
In the second class the starches are supposed to have been 
entirely converted into soluble sugars by the diastatic action 
of the malt. In the third class but a small portion of the 
starch is converted by the process of cooking. 

Among the first class may be mentioned condensed milk and 
evaporated cream, Prof. Gartner's mother's milk and Ramogen, 
Mellin's Food and peptogenic milk powder. In the second 
group, the malted foods, are Pestle's food and malted milk. 
In the third class a farinaceous or dextrinized food is Imperial 



INFANT FEEDING 



139 



Granum, which may be temporarily used alone or in combina- 
tion with milk. 

Mellin's food is used with milk as a modifier, it being claimed 
that it acts as an attenuant to the curds of cow's milk. 

Peptogenic milk powder is used with milk and the mixture 
submitted to heat. By this process the proteids are converted 
into absorbable peptones. Nestle's food and malted milk when 
diluted are deficient in fat and proteid. 









2* 




CARBOHY- 






[C 






DRATES. 








w 


w , 










►^ 3 




^ 


a o 


o 






•< o 






O Ph 








gs 


Eh 
<1 


« 


§fc 


<! 


Sol. 


Insol. 


"" 


^ 


Pm 




J 






13.26 


4.13 


2.00 





6.93 








12.61 


3.75 


3.76 





4.42 








5.18 


0.53 


0.65 





.78 


3.12 





13.97 


4.38 


2.09 





7.26 








8.09 


0.59 


1.12 





5.09 


5.09 


1.13 


7.43 


0.68 


1.15 


trace 


1.18 


4.20 





12.00 


2.85 


2.62 





3.25 


2.73 





7.24 


0.36 


0.^6 


0.45 


0.84 


3.01 


1.99 


8.47 


1.54 


1.67 


0.48 


2.71 


0.58 


1.22 


11.33 


4.16 


1.72 





5.41 


5.41 


5.41 



Mother's milk 

Cow's milk 

Condensed milk 

Peptogenic milk powder. . 

Milkine 

Malted milk 

Mellin'sfood 

Nestle'sfood 

Imperial granum 

Eskay's albuminized food 



0.20 
0.68 
0.10 
0.26 
0.11 
0.29 
0.47 
0.13 
0.34 
5.41 



Gavage. This method of feeding is a valuable one in certain 
classes of cases in which a child will not eat or is too weak to 
do so, or in which vomiting occurs immediately after food is 
taken. The same steps are taken as in stomach washing (see 
page QQ). The food mixture is poured into the funnel and 
when it has been seen to pass the glass tube connecting the 
catheter with the rubber tube, the catheter is compressed tightly 
and quickly withdrawn. Gavage may be performed with the 
patient in a recumbent position or held upright in the nurse's 
lap, leaning against her shoulder. The writer had the pleasure 
of observing the cases at the 'New York Infant Asylum when 
an interne there, reported by Dr. Kerley in the Archives of 
Pediatrics, February, 1901. It was found in these cases, many 



140 THE DISEASES OF CHILDREN 

of them of persistent vomiting, that water or food introduced 
into the stomach througii the tube was retained when a very 
much smaller quantity given by the mouth from a spoon or 
bottle would not be retained. Young children stand the intro- 
duction of the tube without discomfort, and gavage can be used 
for a very much longer period of time than rectal feeding can 
possibly be tolerated. A very weak-modified milk, plain or 
peptonized, cereal decoctions, the concentrated foods, as pano- 
pepton and stimulants, may be given in this way. In cases of 
diphtheria or those wearing an intubation tube, the stomach 
tube is best introduced through the nares. 

Rectal Feeding. This method of nourishment is a valuable 
one when all others have failed, and may be the means of tiding 
over a desperate case until nourishment can be given in other 
ways. The food for administration in this way should be as 
near as possible free from fat and completely peptonized. Com- 
pletely peptonized or pancreatized skimmed milk, mixed with 
albumin water of double strength, namely, the whites of two 
eggs and a pint of water, can be used to advantage. This should 
be heated to about 100° F. as it loses several degrees of heat 
in its passage through the tube of the fountain syringe, if this 
syringe is used to insert it. The food is best inserted through 
a small-size short rectal tube (E'o. 14A) which can be attached 
to a small rubber tube of the fountain syringe, or the fluid can 
be injected with a hard rubber or glass piston syringe; care 
must be taken to invert the syringe to be sure that all of the 
air is first expelled. The child is placed upon its left side, hips 
elevated by raising upon a rubber-covered pillow, its thighs 
flexed upon its abdomen much as in the Sim's position ; the tube 
is anointed well with vaseline from a tube, and the external 
sphincter also greased. The tube is then inserted slowly to the 
distance of 9 or 10 inches and the nutrient enema slowly injec- 
ted. 'Not more than 3 ounces should be injected in a child of 
six months of age, nor more than 6 ounces in a child of three 
years of age. After the injection the tube is compressed and 



INFANT FEEDING. I4l 

quickly withdrawn, and the child's buttocks compressed firmly 
and the child held in the original position, if possible; if not, 
it is allowed to lie upon its back with legs and thighs flexed. 
These enemas can be given as often as three or four times in 
24 hours, but if given much oftener than this the bowel soon 
becomes intolerant and they are expelled as soon as introduced. 
In this connection might be mentioned the great benefit 
obtained from the high colon injection of water in cases of 
deficient kidney excretion, as the absorption from the colon is 
both rapid and prompt. The method of Murphy suggested 
originally for use in septic peritonitis in both adults and chil- 
dren, viz., the continuous colonic flushing may also be employed 
to advantage. It might be well before the injection of the 
nutrient enema to give a preliminary colon irrigation to 
thoroughly cleanse the lower bowel and render it more absorbent. 



CHAPTEE VIII. 

Diseases of the Nose, Theoat and Larynx. 

acute rhinitis. 

Synonyms. Coi^yza, acute nasal catarrh, snuffles. 

Etiology. The most frequent cause of this condition is a 
growth of adenoid tissne in the nasopharynx. Its occurrence 
in infants is comparatively frequent, and in the presence of 
acute symptoms in the nose the nasopharynx should be inves- 
tigated. Congenital deformity of the nose, or deformity result- 
ing from an injury may mechanically act as a predisposing 
cause. 

Exposure of the child, being uncovered at night, with a wet 
napkin, may cause trouble because of the extra work thrown 
upon the air passages from interference with the skin by chilling. 

Pathogenic organisms are a potent factor, as a dust-laden air. 
A child should never be kept in a room which is being swept. 

Pathology. The entire mucous lining of the nose is much 
congested and swollen, due to an increase in the size of the 
blood vessels and infiltration of lymphocytes in surrounding 
tissues. A watery secretion is at first thrown off, followed by 
a mucopurulent one. 

Symptoms. There is at first sneezing and rubbing of the 
nose; restlessness and difiiculty in breathing through the nose. 
This is specially true in infants when nursing, breathing being 
much interfered with because of the swelling of the nasal 
mucous membrane. Occasionally there is a slight rise of tem- 
perature, rarely more than 2° F. There may be a swelling of the 
submaxillary glands. If the discharge is profuse there may 
be an excoriation of the skin of the upper lip with a formation 
of crusts or scabs at the nares. 

142 



DISEASES OP THE NOSE, THROAT AND LARYNX 143 

Diagnosis. The possibility of g, nasal diphtheria developing 
primarily should be borne in mind, and a careful inspection 
of the nasal mucous membrane made for the presence of a 
pseudomembrane. The nose on examination will be found 
occluded, the red and swollen turbinal tissues touching the 
floor and septum. 

If the condition does not respond to treatment and becomes 
chronic, the possibility of its being a manifestation of congeni- 
tal syphilis must be borne in mind. 

Treatment. Calomel, gr. i to a nursling in one dose, or in 
repeated small doses, or a castor oil purge, will prove beneficial. 

There is no contraindication to air, but there should be no 
draughts. Unless it be very cold, the child does much better 
if out of doors in a protected perambulator. 

A 50 per cent boracic acid solution, as an irrigation, is of 
benefit. This should be followed by a weak boracic acid and 
vaseline ointment, gr. i to gi, applied to the nasal mucous mem- 
brane on a cotton swab. In older children an oily spray of 
benzoinated albolene is of benefit. 



s-Cl 



i 



FIG. 29. GLASS SYRINGE WITH RUBBER TIP. 

The use of cold spinal douches is of gTcat benefit in pre- 
venting attacks in children predisposed to them. An effectual 
method of applying cold to the chest and back is by wringing 
a sponge or coarse Avashcloth out of cold water and rubbing 
the skin back and front as far as the waist each morning, fol- 
lowed by a brisk rub. 

CHRONIC RHINITIS. 

This form is rare in children and follows the acute fre- 
quently or may appear as a manifestation of rachitis, adenoids, 
nasal polypi, which are very rare in children, or any general 
condition of impaired nutrition. A nasal discharge from one 



144 THE DISEASES OF CHILDREN 

nostril should always make one suspicions of a foreign body 
in the nose. 

The removal of the cause of the chronic form is usually fol- 
lowed by relief unless there is a hypertrophy of the turbinate 
bones. The treatment is essentially that of the acute variety; 
antiseptic sprays and douches, Seller's and Dobell's solutions 
are of great benefit. 

ATKOPHIC RHINITIS. 

Atrophic rhinitis is found in children with comparative fre- 
quency, oftener in females than males, and begins more fre- 
quently at about the age of 12, though it may begin earlier. It 
rarely begins after adult life is reached. 

There is a chronic nasal catarrh, often involving the pharynx 
and larynx. 

Etiology. The exact cause is not known. Anemia, unhy- 
gienic surroundings are causes. One of the latest theories is 
that it follows accessory sinus disease, as it is frequently asso- 
ciated with sinus disease. 

Symptoms. There is a thick yellowish discharge, which dries 
quickly, forming thick crusts. These and the discharge beneath 
have a very disagreeable odor, this being known, as in adults, 
as ozena. This odor is characteristic and peculiar to this condi- 
tion, the patient not being, as a rule, cognizant of it at all. The 
child does not breathe readily through the nose because of the 
crusts. Epistaxis is common from dislodgement of the crusts 
following picking of the nose. The facies is much the same 
as found in uncomplicated adenoids, aprosexia, and they fre- 
quently complicate this form of catarrh, in about 5 per cent 
of cases. Hypertrophy of the turbinates is also present in 
about the same percentage of cases. Otitis media is a compli- 
cation met in about 10 per cent of cases. 

Prognosis. This is bad, as far as a cure is concerned. Some 
cases recover spontaneously. 

Treatment. Attention to all abnormal conditions of the nasal 



DISEASES OF THE NOSE, THROAT AND LARYNX 145 

mucous membrane as soon as diagnosed is most important as 
a prophylactic. Active treatment in the form of cleansing 
sprays may be ineffectual because of the tenacity of the crusts. 
Dobell's and Seller's solutions or the following: 

Sodii bicarb. 
Borax 
Table salt 
Equal parts. 

S.: One teaspoon to a tablespoonful in a quart of boiled filtered water, one- 
half to be used in each nostril. 

These solutions are best used in a fountain syringe. 

If the odor is bad permanganate of potash, 2 grains to the 
pint of water, can be used in the same way. 

If the patient is old enough, and is tractable, office treatment 
is efficient. Applications can be made, consisting of iodine, 
2 per cent in glycerine, or ichthyol or nitrate of silver solution, 
2 per cent, wdth massage of turbinates. Plenty of fresh air, 
tonics, iodide of iron, etc., are specially indicated. 

EPISTAXIS. 

A hemorrhage from the nose. 

Etiology. Trauma is the most frequent cause, though it may 
be a manifestation of a general condition, as in typhoid fever, 
scorbutus, hemophilia. JSTosebleed may be the first symptom 
of adenoids, being due to the intense congestion of the turbinals, 
which is secondary to the adenoid growth. 

Older children who have suffered from a rhinitis pick the 
nose to remove encrustations, and an abrasion of the mucous 
membrane frequently results, causing more or less bleeding. 
Young girls who have a very heavy suit of hair are prone to 
have frequent hemorrhages from the nose. 

Rarely it may be a manifestation of puberty as a vicarious 
menstruation. 

Symptoms. Hemorrhage from one or both alae is the prin- 
cipal symptom, or if it is at all severe the symptoms of acute 



146 THE DISEASES OF CHILDREN 

anemia will result. If the bleeding is from the posterior nares 
but little blood will escape from the anterior nares, but will be 
spit up or swallowed. Vomiting always follows this. 

Treatment. The nares should be cleansed and with good 
illumination they should be closely examined for bleeding areas, 
which can frequently be found upon the septum. An applica- 
tion of chromic or trichloracetic acid upon a cotton-tipped appli- 
cator to the bleeding point will usually suffice to arrest it. In 
the milder forms tannic acid, and often adrenalin will suffice. 
The galvanic cautery is most satisfactory if patient can be 
controlled. It may very rarely be necessary to pack the nares 
with a cotton pledget. 

Lemon juice applied to the mucous membrane is an efficient 
styptic agent. 

NASAL POLYPI. 

These growths, which usually arise from the middle turbinate 
bones, are infrequent in infants, but sometimes found in older 
children. They usually have a pedicle much smaller than the 
body of the polyp. 

E^ot infrequently the mucous membrane covering the lower 
and anterior border of the septum is hypertrophied and causes 
an obstruction to the nares much like that from a polyp. These 
polypi may be papillomatous in character, cystic or fibrous. 

Symptoms. 'No symptoms are usually present until the polyp 
is of such size as to mechanically interfere with the breathing 
when they are those of a rhinitis. There is a discharge from 
the nose and inability to breathe with freedom through the 
affected side, headache and restlessness at night. 

Treatment. Removal of the polyp should be done early. It 
may be accomplished by means of the snare, forceps or excision, 
the snare being preferred. 

DISEASES OF THE TONSILS. 

Too much emphasis cannot be placed on the importance of a 
consideration of the tonsils in childhood. They bear an inipor- 



DISEAESS OF THE NOSE, THROAT AND LARYNX 



147 



taut relatiouship to many of the severe illnesses of that age, 
as they are the port of entry of many specific organisms to the 
lymphatic and general circulation. 

The tonsils are situated between the pillars of the fauces, 
and are a collection or masses of lymphoid tissue, which have 
within them a number of crypts. These crypts are lined with 
squamous epithelium. 



* • 






^ 


_,___SURF*0£ 
ggP^ EPtTHELIUW 


TRIANGULARIS ^V'Jf^^SHH 






1 


Wr 6LAN0S 


OUTSIDE ^A ...i^M^WI^^^^M 

TONSILLAR — rtfrrr^TTafffWml'f^^MM 

CAPSULE >^g^^g4^B^j|ftj^l|faBP 

SURFACE i^0^ iC^^^^pQ£^^^&| 

EPITHELIUM MUCOUS "n^^^^^gSS^^SHH 

GLANDS tS^^PA^HBHHHH 

MUSCULAR -JnlHMyftt^l^^^^^^^^H 

HBERS OF CAPSULE^wJBQBp^^^^^B 




^P 


i 


\ 

fi MUSCULAR 
W<— FIBERS OF 
n CAPSULE 

CAPSULE. 


CAPSULC~^«lllil|HII|HH 






WJ 6ERHINAL 
W CENTER 


TRABECULA ^^^^^^^I^^HT 


^ zB^^^^^H 




'■ 




BLOOD — "^IB^^^^^B^ 

VESSEL ^ISIHHHH^S 










MUSCULAR FIBER OF (^^reULE-^^^slMlPlgb 


fifeixinnraiP^ 









FIG. 30. A. CRYPTS, VERY IRREGUL-^R .\ND UNEVEN. CROSS-SECTION OF HUMAN 
TONSIL, AGE 11 YE.IRS, DISSECTED OUT IN CAPSULE. X 10. MODERATELY 
HYPERTROPHIED WITH GREATLY DILATED CRYPTS FILLED WITH DETRITUS.* 



The tonsillar membrane is easily infected and the subsequent 
inflammation results in great swelling of the tonsils, and in 
many cases a rapid exfoliation of the epithelia in the crypts, 
which with the fibrin and serum rapidly fill up the crypts, the 
swollen tonsil being dotted with yellowish-white spots. In the 
catarrhal variety of tonsillitis the crypts are empty, the exfoli- 
ated epithelia being thrown off. Occasionally the crypts contain 
a small concretion of broken-down cells and serum in a hard- 
ened mass, which decomposes, giving to the breath a most dis- 
agreeable odor. 

* Reproduced through the courtesy of Dr. Harry A. Barnes, from the 
September 24 issue of the Boston Medical and Surgical Journal. 



148 THE DISEASES OF CHILDREN 

The relationship between tonsillitis and rheumatism has been 
referred to elsewhere. The local manifestation of this general 
condition should always be borne in mind. 

TONSILLITIS. 

Two forms of tonsillitis can be considered, the acute catarrhal 
and follicular, 

ACUTE CATARRHAL TONSILLITIS. 

Etiology. This variety is more often seen as a manifestation 
of rheumatism. Exposure to cold, wet feet, and indiscretions 
in diet are the most frequent causes. 

Symptoms. The first symptom may be a chill or perhaps an 
elevation of temperature. The child will, more than likely, 
not complain of its throat at all, or perhaps only when it swal- 
lows. It may have pain or discomfort in its joints, manifested 
only by crying when moved or handled. 

Food is frequently refused, due chiefly perhaps to the pain 
in the throat, which is not otherwise complained of. 

The temperature is always elevated, it may be to 103° F., 
which lasts for two or three days, gradually subsiding. There 
are remissions but it does not reach normal. Because of the 
infrequency of complaint in regard to the throat from both 
infants and children no examination should be considered com- 
plete without a thorough inspection of the throat by either a 
good, direct light or a reflected light from a head mirror. 

The tonsils will be found enlarged, very red and granular 
in appearance, and if the child gags when the tongue is de- 
pressed the tonsils may approximate in the center. 

The bowels are usually constipated and it is not unusual for 
vomiting to occur at the onset. 

Prognosis. This is good in an uncomplicated catarrhal ton- 
sillitis, but the danger is always great of an infection occurring 
of the tissue behind the tonsil, and the formation of a localized 



DISEASES OF THE NOSE, THROAT AND LARYNX 149 

abscess. The occurrence of frequent attacks of catarrhal tonsil- 
litis is suggestive of a rheumatic diathesis. 

Treatment. An initial close of calomel in all tonsillar and 
pharyngeal inflammations is a positive indication. The dose 
should be larger than is ordinarily given children, at least 2 
grains for a child two years old. This should be followed by a 
dose of aromatic cascara, milk of magnesia or other palatable 
laxative. 

One of the salicylates should be given, preferably aspirin, in 
dose of 3 grains at three- or four-hour intervals to child of three 
years. 

Locally an astringent application should be made to the ton- 
sils, as Loeffler's solution or tannic acid: 



^ 


Acidi tannic! 
Listerine 






gr. XXX 

oiss 






Aquffi destill. 


q.s. 


ad 


oiii 




M. 


ft. sol. 










Sig. Locally once or twice a day on a swab, 




loeffler's solution. 




n 


Mentholi 






10 gm. 






Toluene 


q. s 


;. ad 36 cc. 




Add. 












Creolin 






2 cc. 






Liq. ferri chloridi 




4 cc. 






Alcoholis 


q.s. 


ad 


100 cc- 


-U 



A cold, wet compress applied to the throat is of great benefit. 
The control of the diet is most important and sweets should 
be eliminated entirely from the bill of fare. 

FOLLICULAR TOITSILLITIS. 

Synonym. Acute lacunar amygdalitis. 

Etiology. The streptococcus, staphylococcus and pneumo- 
coccus are probably the most frequent offenders. They gain 
entrance to the tonsillar crypts and there set up a severe 
inflammation. 



150 THE DISEASES OF CHILDREN 

Exposure to cold or wet, and the rheumatic diathesis are pre- 
disposing causes. 

Age is a factor. It is decidedly more frequent under the 
age of 15 than over that age. Infants under six months of age 
are infrequently affected. 

Symptoms. ^Vhile a distinct chill is difficult to determine in 
a child it may evidence itself by cold and blue extremities, 
pallor of the face and blanched lips. 

In older children the aching of the joints, back and legs is 
quite severe, but the only manifestation of this symptom in an 
infant may be, as in the catarrhal variety, crying when it is 
picked up. 

The temperature is elevated to 103° F. or 105° F., with 
remissions of 1° or so, and lasts from three to four days. The 
pulse is correspondingly rapid. In some the respirations may 
be faster as a result of the temperature and toxemia. 

There is anorexia, often vomiting and the bowels irregular. 
During the latter stage there may be thin and green stools from 
the infection following swallowing of the mucus from the throat. 
Inspection of the throat show^s enlarged tonsils, very red, and 
studded with w^hite spots. These spots are the ends of accumu- 
lations of broken-down epithelium, serum and fibrin in the 
crypts, and as they are squeezed out of the tonsils may coalesce 
on the surface of the tonsil and form a pseudomembrane. 

The pharynx is deeply congested and sv^ollen, and the uvula 
edematous and red also. This condition may be present and 
no complaint of the throat be made, which emphasizes the 
importance of a careful examination of the throat in every case 
of illness in a child. 

The lymph nodes at the angle of the jaw and under the 
ramus may be enlarged. The tonsils can be easily palpated 
externally. 

The duration of an attack is usually four or five days, the 
temperature falls by lysis, the tonsils are clean and gradually 
reduced in size, and the aching is entirely relieved. 



DISEASES OF THE NOSE, THROAT AND LARYNX 151 

Complications. Infection of the middle ear, retropliar^'ngeal 
and retrotonsillar abscess may complicate the convalescence. 

Prognosis. In uncomplicated cases this is good. 

Diagnosis is chiefly to be made from diplitheria. This fre- 
quently cannot be made without a careful bacteriologic examina- 
tion. In suspicious cases a culture should ahvays be made. 
Again a case may begin as an uncomplicated follicular ton- 
sillitis and develop into diphtheria. The pseudomeinbrane in 
follicular tonsillitis can be removed without leaving a bleeding- 
surface below as occurs in diphtheria. 

Treatment. CalomeT should be given as soon as the diagnosis 
is made, followed by a saline if possible. A portion of a bottle 
of citrate of magnesia can be given usually. Castor oil is also 
of benefit. 

If the child is old enough to gargle a 50 per cent solution of 
peroxide of hydrogen is of great service in softening and remov- 
ing the exudate. Any mild antiseptic solution can be used as 
a gargle, Dobell's and Seller's solutions are efficient. 

Locally the tonsils should be touched with a mop saturated 
with an astringent solution, as tannic acid or Loeffler's solution. 

The application of powdered aspirin directly to the tonsil 
has been suggested as an excellent remedy. 

Internally aspirin should be given, as in catarrhal tonsillitis, 
followed during convalescence by the tincture of the chloride 
of iron. 

I^ Tinct. ferri chloridi 51 

Glycerine 5 iii 

Aquae destillat. q. s. ad gii- — ^1- 
Sig. One teaspoonful every three hours, diluted. 
Rest in bed and isolation are positive indications and should be insisted upon. 

Chronically Enlarged Tonsils require surgical intervention. 
Whenever several distinct attacks of tonsillitis have occurred 
in a child, leaving in the interim much enlarged tonsils, or when 
associated with aural complications as progressive deafness, 
catarrhal and suppurative otitis media, or persistent enlarge- 



152 THE DISEASES OF CHILDREN 

ment of the glands of the neck, they should be removed, as they 
are a constant menace to the child from infections of many 
kinds. 




FIG. 31. TONSILLOTOME. 

In a young child, this operation should always be done under 
a general anesthetic, somnoform, gas, ether or chloroform. The 
operation is not as easily done under a general anesthetic as 
without, but the inconvenience to the operator is more than 
counterbalanced by the comfort of the patient. It is brutal 
to forcibly hold a child and remove first one tonsil and then the 
other, and the shock to the nervous system is one which is 
recovered from only after a great while. I appreciate that this 
opinion is at variance with the ideas of many specialists, yet I 
am convinced this is correct. 

The Mackenzie instrument, the tonsillotome or guillotine, 
may be used. It may be thought necessary to excise the tonsil 
entirely. This may be done by holding the tonsil with a volsel- 
lum, and excising with a bistuory. 

The tonsils should not be removed too soon after an acute 
attack of tonsillitis, as the danger of postoperative hemorrhage 
is too great. There have been a number of deaths from hemor- 
rhage after tonsillotomy, and this danger should always be borne 
in mind. 

TJVULITIS. 

An elongated uvula is sometimes seen in older children, 
rarely in infants. 

Symptoms. There is an irritation in the throat, a hacking 
cough, especially when the patient is recumbent, and a constant 



DISEASES OF THE NOSE, THROAT AND LARYNX 153 

desire to swallow. There may be pain on swallowing. The 
congh may be suggestive of bronchitis, but no signs are found 
in the chest, unless there is an associated bronchitis. 

Treatment. The application once or twice daily of an astring- 
ent solution will usually suffice. The folloAving is recommended : 

]^ Acidi tannic! 3ss 

Glycerini 3ii 

Listerine o ii 

Aquae dest. q. s. ad §m 
M. et ft. sol. 
Sig. Apply on cotton swab to uvula. 

In older children a gargle of Dobell's solution is beneficial. 
If the condition is chronic and does not respond to local appli- 
cations, an excision of the tip of the uvula may be necessary. 
Care should be taken to limit the excised portion to the tip of 
the mucous membrane, not cutting the muscle, in which event 
the pain following is very severe. 

Cold applied by eating ice, and cold cloths externally is of 
great benefit in relieving the pain following the operation. 

PERITONSILLAR ABSCESS. 

Synonym. Quinsy. 

Etiology. An infection from a tonsillitis or diphtheria is 
usually the cause. This affection is very rare at the extremes 
of life. 

Symptoms.. Pain in the throat, inability to swallow without 
its being greatly exaggerated and a peculiar voice, as if it were 
full of hot mush, are the principal symptoms. Stiffness of the 
neck, pain on opening the mouth, and pain referred to the ear. 
There is also an increased flow of saliva, which is swallowed 
with difficulty. An examination shows a very edematous area 
near the tonsil, which usually is very glassy in appearance. The 
uvula is pushed to one side by the accumulations of pus from 
behind. 



154 THE DISEASES OF CHILDREN 

Prognosis. A few cases have been known to rupture during 
sleep, pus entering the larynx, producing death by strangulation. 
Edema of the larynx may follow also. 

Treatment. The accumulation may be quite tense and require 
but a very superficial incision to evacuate the pus. The posi- 
tion of the ascending pharyngeal artery must be remembered in 
making the incision. In others the pus is difficult to locate as 
it constantly burrows behind the fascia but finally toward the 
surface and may rupture spontaneously. Relief is almost imme- 
diate as soon as the abscess is drained. 

Hot applications and hot gargles assist materially in reducing 
pain and hastening rupture. 

RETKOPHARYNGEAL ABSCESS. 

The retropharyngeal nodes become infected by bacteria 
through the medium of the lymphatics, in tonsillitis, measles 
and other septic conditions. It may be due to vertebral caries, 
and as a complication of tuberculosis, rickets and syphilis. 

It occurs comparatively frequently in infancy and childhood, 
especially during the first year. 

Symptoms. The acute symptoms, pain and obstruction to 
swallowing, may begin abruptly. The glands at the angle of the 
jaw are swollen and tender. The usual examination of the 
throat may reveal the cause of the trouble at first glance, and 
the finger introduced in the mouth will feel the doughy tumor 
extending beyond the reach of the finger. Hoarseness is pres- 
ent if the abscess presses down upon the larynx. 

Treatment. The positive indication is to open the abscess 
and evacuate the pus through an opening as large as possible. 

I have seen one child in which the first examination by the 
finger caused great dyspnea, necessitating intubation. 



diseases of the nose, throat and larynx 155 

Diseases of the Larynx. 

acute catarrhal laryngitis. 

Syiionyms. Croup. Spasmodic croup. 

Etiology. Exposure to cold is the most frequent predispos- 
ing cause, any of the bacteria found in the throat in tonsillitis 
may be the active cause of the inflammation. The bacillus of 
diphtheria is not present, as a membrane would be the result 
of such invasion and a true croup caused. 

Symptoms. The child is usually put to bed in apparently a 
normal condition. It may perhaps have had a slight hoarseness 
or a hacking cough during the day or several days previously, 
or a slight coryza without the cough. xVfter having been asleej) 
for sometime it will cough, the sound produced being harsh and 
brassy which is the characteristic croupy cough, and which 
strikes terror to every mother's heart. This cough may awaken 
the child, and there is a rasping character to the inspiration 
and the cry, which may be heard and recognized some distance 
away. If very severe the child may show considerable pallor 
and exhibit other symptoms of dyspnea, clutching at the throat 
with a recession of the supraclavicular and infraclavicular spaces 
with each inspiration. The skin is clammy as a rule, though 
there may be a dusky flush to the cheeks if there is any fever, 
which may reach 103° F. or 104° E. 

The spasmodic stage may last some hours, but it is usually 
shorter in duration, and by morning the child is asleep and 
breathing quietly. During the day it wull play around with- 
out, as a rule, much hoarseness evidencing itself. The croupy 
cough, how^ever, usually recurs the following night or for several 
nights, however, less severe as a rule. 

Diagnosis. This must be made from diphtheria. In this the 
symptoms grow gradually worse, instead of disappearing dur- 
ing the day, to recur at night, as in catarrhal laryngitis. Some 
membrane is usually present in other parts of the throat, in 
diphtheria. 



156 



THE DISEASES OP CHILDREN 



In laryngismus stridulus, the pronounced croiipy congh is not 
so prominent, the dyspnea and stridor being most marked. 
There is no fever in laryngismus and the duration is shorter. 
The constitutional condition of which laryngismus is a symp- 
tom, ricketSj is more often present in the latter than in croup. 

Prognosis. This is good when uncomplicated. 

Treatment. If the stridor is great, the best results can be had 
by giving a preliminary dose of syrup of ipecac in -20 to 60 
drops dose, for its full effect upon the stomach. After vomit- 
ing, the whole aspect of the case is usually changed, as by doing 
so the mucus in the trachea and larynx is dislodged and this 
mechanical obstruction removed. This dose can be repeated at 
half hour or hourly intervals as needed to produce emesis. 
Continuing the effect of relaxation, good results are had from 
antimony and ipecac, 1/100 grain each, every hour. 




FIG. 32. CROUP KETTLE. 

Excellent results are had from allowing the child to breathe 
steam, and the '^croup kettle" which generates steam by the 
bedside, should be used. One teaspoonful of the tincture of 
benzoin to a pint of water vaporized is of great service. When 
the child is asleep a sheet tent should be erected over the crib 
so as to confine the steam. The kettle, as long as the lamp is 
lighted, should be closely watched and not left unattended at all. 



DISEASES OF THE NOSE, THROAT AND LARYNX 157 

For severe cases, with great recession of the spaces, and 
apparent danger of complete obstruction, intubation, as for 
diphtheritic laryngitis, should be performed. 

The application of a wet, cold compress is of service in reduc- 
ing the swelling of the vocal cords. 

ADENOIDS. 

Pathology. An hypertrophy of the lymphoid tissue or the 
mucous glandular tissue in the nasopharynx or vault of the 
pharynx is designated as an adenoid growth. The growth may 
be lobulated and attached by one base, or there may be more 
than one of these masses. The mass when removed may resemble 
a bunch of grapes in its conformation. 

Owing to the passive congestion of the nasopharyngeal mucous 
membrane from pressu.re and mechanical irritation of the 
growth there is a constant secretion of mucus, escaping through 
the nares and into the throat. 

Bacterial growth in the nasopharynx in which there are 
adenoids is very active, the pneumococci, streptococci and staph- 
ylococci being most often found. 

The mucous membrane around the opening into the Eu- 
stachian tube, and extending up the tube, is congested and 
swollen, and bacteria are present. 

The frequency of adenoids has been given as from 15 to 50 
per cent of all children. It is often a family characteristic. 

Symptoms. A child with adenoids usually presents a train 
of symptoms which are fairly characteristic. It is more than 
usually susceptible to ''colds,'' having the snuffles and a constant 
nasal discharge; breathes through the mouth, both asleep and 
awake, but especially when asleep and lying upon its back; it 
is inattentive from deafness, and apathetic, due to impoverished 
blood from respiratory obstruction ; complains frequently of 
earache. 

After adenoids have existed some time the change which 



158 THE DISEASES OF CHILDREN 

takes place in the conformation of the face is fairly character- 
istic. Gnje has designated this facies as aprosexia. There is a 
peculiar prominence of the nasal bones, giving a tendency to 
an appearance called hatchet face, the lips are partially open 
to permit of month-breathing, as it is impossible for a free 
exchange of air to take place through the nose. 

It has been generally believed that adenoids were peculiar 
to children beyond the age of two years, but it has been found 
by a number of observers that they occur in early infancy, the 
earlier they occur the more serious the after-effects, unless 
early remedied. There is a greater tendency to recurrence of 
the growth after removal in the very young. 

Owing to the low position of the nasopharynx in infancy 
and its relatively greater length from before backward, and 
the smallness of the nose and its cavities, a very small growth- 
causes greater obstruction. The presence of adenoids in an 
infant interferes with its nasal respiration to such an extent 
that sucking and swallowing are much interfered with, and 
these interferences with nutrition, and insufficient oxvgeii, 
cause a condition of malnutrition which is oftentimes very 
serious. All of the diseases of malnutrition, especially rickets, 
are apt to follow, deformities of the chest, the so-called pigeon 
breast, is frequently seen. It is often necessary to differen- 
tiate adenoids in which there is a constant ''snuffles" from con- 
genital syphilis. Infants so affected are restless at night, waking 
frequently, and this interference with proper rest adds greatly 
to the state of malnutrition. The following application may l)e 
made to the adenoid-bearing area to cause absorption. 

I^ Tinct. iodini oss 

Menthol gr. ss 

Benzoinated albolene 5i- 
M. Sig. Five drops in anterior nares with child lying on back. 

In later childhood it is rare to find a case presenting adenoids 
that does not also show considerable enlargement of the faucial 
tonsils, and it is a fact frequently recognized that if the adenoids 



DISEASES OF THE XOSE^ THROAT AND LARYNX 159 

are removed aud tlie faucial tonsils left tlie tendency to the 
recurrence of adenoids is very great. 

Owing to the tendency to rapid propagation of pathogenic 
bacteria in the nasopharynx in which there are adenoids the 
complication of infection of the middle ear is very frequently 
observed. The nasopharynx is filled by the growth which 
presses on the opening of the Eustachian tube; this interferes 
with the air in the middle ear and deafness, which is a prom- 
inent feature of these cases, is caused. 

Treatment. There is but one treatment for adenoid growth 
and that is surgical. A number of observers have tried the 
effect of local application of absorbof acients and internal admin- 
istration of the iodides with no effect whatever. There is per- 
haps no operation that in itself is so simple, which gives rise to 
such excellent and prompt results, as the cleaning otit of the 
nasopharynx of an adenoid growth stifficient in size to give 
symptoms. 

In infants the removal can frequently be accomplished with- 
out the use of instruments, as the mass of tissue is so soft as to 
make it possible to crush it and remove it by the finger. 

In older children it is my opinion that the operation should 
never be done without a general anesthetic. The dangers of 
the anesthetic are greatly outweighed by the shock to the ner- 
vous system, from forcibly holding the patient and brutally 
scraping out this growth. Cases in which this operation is 
done withotit an anesthetic are much more apt to have the 
growth rectir from the incompleteness of the operation. In 
competent hands the best anesthetic is chloroform. I make 
this statement in spite of the statistics showing the comparative 
greater safety of ether over chloroform. I have given chloro- 
form for this operation a great number of times without ever 
seeing a dangerous symptom. The patient should be rectimbent 
upon the table upon which the operation is to be done, and the 
anesthesia produced should l)e only to the primary degTee. The 
mouth gag of the O'Dwyer intubation set is then introduced, 



160 THE DISEASES OF CHILDREN 

the head brought well to the edge of the table and below the 
level of the body, the face turned to one side. The hair is pro- 
tected from soiling with the blood by a rubber bath cap which 
fits snugly over the forehead and under the occiput. With the 
patient anesthetized only to the primary stage there are still 
some reflexes present, and the tendency to swallow blood is 
much less than if they are completely under the anesthetic. 
There are few operations in which the loss of blood is as great 
for the amount of work done, and for this reason it is always 
well for members of the family not to be present during the 
operation. 

The child lying upon its back, the shoulders are pulled to 
the edge of the table, the head lowered, with the face turned 
to the side, the mouth held open with the gag and the finger 
as a guide, the growth is removed by means of the curette, 
which ordinarily will remove the entire mass in one or two 
scrapings. The roof of the pharynx must be carefully inves- 
tigated with the finger to ascertain if entirely clean. The 
danger of secondary hemorrhage is very slight, although a 
few cases have been recorded of this nature. After cleans- 
ing the face the child is put to bed with head flat, and the 
family warned of the possibility of its vomiting blood which 
may have been swallowed during the operation. If there is no 
nausea following, in the course of an hour or so, crushed ice 
may be given the patient if it craves water, and later ice cream 
or cold milk when nourishment is necessary. 

As a rule no after treatment is needed, and the beneficial 
effects of the operation while generally not immediate are very 
soon noticed in the relief of all previous disagreeable symptoms, 
the first usually to disappear is the snuffles or symptoms of cold 
in the head. There is a change in the voice and the child is 
less restless at night, and the mouth-breathing soon disappears. 
In those who have been in the habit of breathing through the 
mouth for some time it may be necessary to frequently remind 
them of the necessity of keeping the mcaith closed. 



CHAPTER IX. 

Diseases of the Eak. 

Deafness in children is much more frequently present than 
is ordinarily thought, and in school children may prove a serious 
handicap to their progress. In this period any defect in hear- 
ing will interfere with the development of speech, and inatten- 
tion and slow mental development is the result. Inattention 
in an otherwise normal child should cause an examination to 
be made of the child, and this emphasizes the importance of the 
regular medical inspection of school children. 

Adenoids is perhaps the most frequer^t cause of deafness; 
next being nasopharyngeal catarrh, with an occlusion of the 
Eustachian tube and the extension of the inflammatory process 
to the middle ear. These children if watched at play will be 
seen to have less endurance, and this is exaggerated in damp, 
humid weather. 

Every child should be examined at school for acuteness of its 
hearing, and in the presence of its teacher. If the hearing is 
found defective, an otologist should be consulted in order to 
locate the cause of the defect. 

This is one of the many advantages which can be gained from 
medical inspection of schools. 

External Auditory Canal. 

FURUNCULOSIS. 

The most frequent condition affecting the canal is a furun- 
culosis of the skin inside the meatus. This is not often seen 
in young children but comparatively often in those approaching 
puberty. 

Etiology. The practice of children putting foreign bodies 
in their ears is a potent factor. This causes an abrasion of the 

161 



162 THE DISEASES OF CHILDKEN 

skin and an infection, usually by the staphylococcus, which in 
one form or another are normally found in the hair follicles 
of the canal. In older children the employment of pin heads 
and sharp instruments to give relief from itching or to clean 
out the normal secretion of wax results in an infection. 

Pathology. There may be a diffuse inflammation of the skin 
of the entire canal, or one or more discrete furuncles. The 
swelling may be diffuse enough to make an examination of the 
drum impossible. 

Symptoms. Perhaps more pain is caused by inflammation 
located here than at any other part of the body, owing to the 
tenseness of the tissues of the canal. Pressure pain develops 
early, and if the furuncle is located near to the meatus move- 
ment of or touching the external ear causes pain. There may 
be a slight rise of temperature, to 101° P., occasionally, loss 
of sleep and of appetite, with general depression and irritability. 
Unless relieved by incision, the furuncle generally ruptures 
spontaneously during the first week and immediate relief is 
afforded by the escape of pus and blood. Unfortunately one 
boil may be followed by another, as it is next to impossible to 
keep the parts sterile after discharge of pus from the first one 
takes place. 

The location of the boil can be made out by the use of a 
cotton-protected probe. A speculum cannot always be used on 
account of the tenderness. Mastoiditis must be differentiated 
from, which is chiefly done by pressure on the mastoid bone, 
eliciting tenderness in the latter only. 

Treatment. Abortion of the boil is possible. This can some- 
times be effected by leeches applied just external to the auditory 
canal, care being taken to plug the canal with cotton to prevent 
their migration into it. Locally, cotton, saturated with a 50 
per cent ichthyol and glycerine solution may be of benefit. The 
continuous application of heat by irrigation with a fountain 
syringe is of great benefit. Efforts at aborting the boil being- 
ineffectual, an incision is absolutely necessary, and this should 



DISEASES OF THE EAR 163 

be made with a special furuncle knife with a triangular or a 
half -curved blade, and the incision made through the furuncle 
and the tissue on either side of it, thus draining the collection 
of pus and reducing the congestion also. 

This operation is so painful that the administration of a 
general anesthetic is urged. Somnoform or laughing gas is most 
efficient, having the advantage of lack of after-effects, nausea, 
etc. If these are not available, chloroform to the primary stage 
should be used. 

If these furuncles are recurrent the injection of the bacterial 
vaccines is recoimnended. 

Local antiseptics and cleansing should constitute the after 
treatment, probably using irrigations two or three times a day. 

IMPACTED WAX. 

The natural secretion of cerumen may be increased in amount 
and collect in the canal, and when mixed with the epithelium 
of the canal may obstruct the entire meatus. The mass may be 
pushed inward and press against the drum. This frequently 
causes symptoms such as tinnitus, gradual deafness, a sense of 
fulness in the ear, or more or less pain, dizziness and perhaps 
vomiting. An examination of the ear with a good, reflected light 
is sufficient to make the diagnosis. At first it may resemble a 
foreign body in the canal. 

Treatment. The wax may be removed with a curette if close 
to the orifice, but frequently will have to be softened by repeated 
syringing with warm water in a piston syringe. The force 
obtained from a fountain syringe will not disintegrate the mass 
as a rule. The fluid used should either be plain sterile water, 
normal salt solution or saturated boracic acid solution. 

If syringing does not succeed in disintegrating the mass, a 
solution can be used as follows for instilling into the ear three 
times a day, until the wax has softened: 



164 THE DISEASES OF CHILDREN 



Acid carbolic 


m.i 


Acid boracic 


gr. XX 


Sodium biborat. 


gr. X 


Glycerine 


5ss 


Aquae dest. 


§ss 



A dry dressing of powder should be blown in the ear after 
the wax has been removed. 

THE MIDDLE EAR. 

The student and practitioner should familiarize himself with 
the appearance of the normal drum membrane, should be able 
to locate the landmarks, as follows: The short process of the 
hammer ; the handle of the hammer or malleus ; the triangular 
light spot. The normal color is a pearl-gray, and abnormal 
conditions evidence themselves chiefly in a change of color of 
the drum. 

Inflammations of the middle ear are either suppurative, which 
may or may not have been the result directly of an extension 
upward of an inflammation of the Eustachian tube. 

ACUTE TUBOTYMPANIC CATARRH. 

Etiology. Whether the normal middle ear contains bacteria 
is a debatable question, equally prominent authorities holding 
opposite views. Bacteria may gain entrance to the tympanic 
cavity through an opening in the drum, the result of trauma, or 
through the Eustachian tube. They may obtain entrance also 
via the blood and lymphatics. 

The most frequently-observed bacteria are the streptococcus, 
staphylococcus; though the following may be found, the pneu- 
mococcus, the bacillus pyocyaneus, Klebs-Loeffler bacillus, the 
meningococcus intracellularis, influenza bacillus and the colon 
bacillus. 

Nasopharyngeal adenoids are one of the most frequent causes 
of catarrhal inflammation of the mucous membrane of the 
middle ear. They are the most frequent cause of the so-called 



DISEASES OF THE EAR 165 

colds and acute coryza which so frequently precede an acute 
tympanic catarrh without suppuration. 

Pathology. Inflammation may rarely be limited to the Eu- 
stachian tube, but usually extends to the cavity as well. As a 
result of the inflammation, swelling and occlusion of the Eu- 
stachian tube there is a slight accumulation of serum and an 
absorption of the air in the middle ear, and a coincident inward 
depression of the drum membrane. 

Symptoms. The first symptom which is present is usually an 
impairment of hearing, followed by a sense of fulness on the 
affected side, ringing in the ear, perhaps dizziness. When the 
catarrhal inflammation extends to the middle ear there is a 
swelling of the mucous membrane and more or less pain. 

In the early stages, when most of the involvement is in the 
Eustachian tube, the drum membrane is retracted, but subse- 
quent examinations may show a collection of fluid in the cavity. 

Prognosis. Early recognition and prompt treatment make 
the prognosis favorable. The restoration of a diseased condi- 
tion of the nasopharynx to normal greatly influences the prog- 
nosis and limits the possibilities of a return of the condition. 

Treatment. When only the tube is involved, with more or 
less occlusion, it must be opened, either by the Eustachian 
catheter or by the Politzer bag. The catheter is entirely imprac- 
tical in children, and inflation of the drum by the Politzer bag 
yields the best results. 

Eirst cleanse the nose and pharynx with an antiseptic spray 
(DobelFs solution or Seller's solution), followed by a nebulizer. 

Several methods of Politzeration are advised. The child 
is seated, the tip of the bag is placed well in the nostril of the 
affected side and held, the opposite nostril being compressed. 
The child is then told to count one, two, three, and as the last 
word is said the bag is squeezed, which usually effectually in- 
flates the affected side. The child may be told to fill the lungs 
with air and forcibly to blow it out through puckered lips, the 
bag is then squeezed and the drum inflated. In older children 



166 THE DISEASES OF CHILDREN 

the inflation can be accomplished as a swallow of water is 
taken, biit in younger children this is impractical because of 
the danger of choking. 

The Politzeration should be done every day for three or four 
days, and then every other day, and finally once a week for 
several weeks. 

In the presence of a collection of fluid in the cavity a para- 
centesis or incision of the drum should be done. 




FIG. 33. FOR PARACENTESIS OF THE DRUM. 

For this operation a general anesthetic should always be 
given as the pain is very acute. The necessity for a paracentesis 
rarely exists imtil the patient has already suffered acutely for 
a number of hours, probably having lost much sleep ; hence the 
infliction of additional acute pain should not be allowed. Local 
anesthetics are not of much avail. The following can be used 
with some benefit: 

I^ Cocaine muriat gr. x 
Ac. boracic saturated sol. 
Alcohol aa 5i 

M. Politzeration should be performed after paracentesis. 

ACUTE CATARRHAL OTITIS MEDIA. 

Pathology. The mucous membrane lining the middle ear is 
acutely inflamed and swollen, and an exudate usually occurs, 
being either serous or mucous, bathing the mucous membrane. 
There may be an accumulation suflicient to fill the cavity. 

Etiology. A^Hiile this condition may occur as a primary 
affection it is usually an extension of the process from the naso- 
pharynx, any of the bacteria named in the previous section 



DISEASES OF THE EAR 167 

being found in the tympanic cavity. Bacteria in the naso- 
pharynx may be forced in the cavity through the tube by nasal 
douches or sprays, gargling or coughing when swallowing. 

As a complication in the acute exanthemata, this form of 
otitis is most frequent. 

Symptoms. Any severe pain in the ear is always suggestive 
of this form of trouble. It is at first a dull, deep-seated ache, 
gradually increasing in severity until it becomes sharp and 
lancenating; sleep is impossible, and older children walk the 
floor holding the affected side. Remissions in the severe pain 
are hardly long enough to allow the child to fall asleep, crying 
out with each exacerbation. Younger children usually pull at 
the affected side. 

If old enough to tell, the watch test evidences deafness to a 
greater or less degree, according to the severity of the inflamma- 
tion and amount of effusion. Some complain of the ringing in 
the ears, in others this is less noticeable. 

Pain is severe until the fluid in the ear escapes, either through 
a spontaneous rapture in the drum or a paracentesis of the 
drum is performed, when the feeling of relief is immediate and 
the child falls asleep. 

In children there is usually a rise of temperature, from 1° 
to 3° F., though there may be no rise at all. As a complication 
of the exanthemata there is nearly always an elevation. A child 
may waken in the night with an earache, having previously 
suffered from an acute coryza, perhaps have a slight remission 
in the pain during the day, with a recurrence of it at night, 
permanent relief being had only after spontaneous rupture of 
the drum and escape of the mucus or serum, and all of this 
without elevation of temperature. This rupture may occur in 
12 hours after the onset of the pain, but may be delayed for 
three days. 

The drum membrane, if examined before rupture, is found 
to have changed to a deep or cherry-red color, the landmarks 
have disappeared, and if the exudation has occurred in the 



168 THE DISEASES OF CHILDREN 

cavity the drum bulges outward in some portion, usually it 
being greatest in the upper, posterior portion. If the drum 
has previously ruptured the canal is filled with exudate, and a 
free view of the drum cannot be had without a previous cleans- 
ing with a cotton-protected swab. 

Untreated or neglected cases of the catarrhal variety of otitis 
usually develop into the suppurative form, especially after a 
perforation of the drum has occurred. The opening in the drum 
from a perforation is usually found in the inferior quadrant, 
to the right or left. 

Prognosis. The majority of these cases completely recover. 
The condition of the nasopharynx influences the prognosis. 
Persistence of a nasopharyngeal catarrh, adenoids and anemia, 
tend to the likelihood of recurrence of this trouble. 

Treatment. If seen early, before there has been a perfora- 
tion of the drum, an anodyne is necessary, opium in some form 
being most efficacious. The camphorated tincture or the deodor- 
ized tincture may be used. 

The tampon suggested by Barnhill, in the canal, is of service 
also. A cone of cotton is twisted on the end of an applicator, 
saturating the end of the cotton with a phenol (10 per cent) and 
glycerine (90 per cent) solution, and holding it over a flame 
until as hot as can be stood on the back of the hand, and before 
it has had time enough to cool it is removed from the appli- 
cator and carried back against the drum membrane w4th the 
end projecting from the meatus. 

I have found excellent results follow the use of an irrigation 
of the ear with a fountain syringe, using water as hot as could 
be borne and holding the syringe not more than 12 inches above 
the head, thus doing away with the pressure against the drum. 
The child should be persuaded to put his hand in the water for 
a moment to become familiar wuth its temperature before it is 
used in the ear. 

Usually before the physician has been called the mother has 
dropped into the ear some warm sweet oil and laudanum which, 



DISEASES OF THE EAR 169 

as long as it retains its lieat, is effectual, but little absorption of 
the laudanum occurring. 

Paracentesis of the drum should be performed as soon as a 
bulging drum has been found. This should be done under strict 
antiseptic precautions and in the subsequent treatment being 
most careful to prevent infection. Rest in bed, if fever is pres- 
ent ; indoars, if the child is up. 

An occasional dose of calomel, 1 grain at a dose at bedtime, 
followed by a saline the next morning ; syringing the discharging 
ear frequently; at first, every two or three hours, daily after 
this; drying of the canal by cotton swabs and insufflation of 
canal with boracic acid powder constitute the treatment which 
generally yields the best results. 

A sudden cessation of the discharge, an increase in or return 
of pain, rise in temperature, usually indicates a too early closure 
of the drum. 

ACUTE SUPPURATIVE OTITIS MEDIA. 

This form may follow the catarrhal otitis or originate as the 
suppurative form. A large percentage of cases of deafness are 
due to this variety of inflammation, and chronic otitis is a 
frequent ending. 

Etiology. One of the most frequent causes is bacterial inva- 
sion of the tympanic cavity as a complication of influenza. 
Large numbers of acute-discharging ears are seen every winter 
in which influenza is epidemic. 

The exanthemata, especially scarlatina and diphtheria, are 
frequently complicated by suppurating middle ears. In the 
former disease infection of the ear most frequently follows the 
membranous form of angina. The streptococci are most fre- 
quently found as the infecting organism. 

As in the other varieties of middle ear involvement, the pres- 
ence of adenoids is an exciting factor in middle-ear suppuration. 

Symptoms. ]N'o other condition of the ear presents such a 
variety of symptoms as this. Some may be present with severe 



170 THE DISEASES OF CHILDREN 

constitutional and local symptoms, as a temperature ranging 
from normal to 103° or 104° F., severe prostration, deafness 
and agonizing pain in the ear. In others one of the first symp- 
toms will be the discharge from the ear following, perhaps, a 
sense of discomfort or fulness in the affected side. 

It is usual, however, for the trouble to be ushered in with 
severe pain, deafness, tinnitus, perhaps vertigo or dizziness. 

The accompanying chart is of a patient three years of age 
who presented but few symptoms before the discharge began, 
and practically none afterward, except the temperature, loss of 
appetite and some loss in weight. The discharge was profuse, 
and when the opening in the drum became slightly closed, caus- 
ing retention of secretions, all of the symptoms were aggravated. 

When occurring as a complication in the exanthemata there 
is usually a rise in the temperature, especially if the suppura- 
tion occurs late in the course of the disease, as may be the case. 

Usually with the rupture of the drum the pain subsides imme- 
diately, and the child is free from pain unless the opening 
becomes blocked with discharge, when pain is again severe. 
Where the child has been previously restless and crying, as soon 
as the rupture takes place it falls into a peaceful sleep. It is 
astonishing to see the amount of discharge which may come from 
the middle ear. It is usually thick and yellow, caking in flakes 
upon the ear and beneath when it is profuse enough to run over. 

It is impossible to state the character of the secretion in the 
middle ear by the looks of the drum membrane, though in the 
suppurative form there is apt to be a larger amount, hence more 
bulging. The membrane is reddened, more or less uniformly, 
except at the site of the rupture, which may be imminent, this 
showing signs of necrosis by change in color. 

The opening in the drum as a result of a spontaneous rupture 
may vary from a slit to a practical washing away of the entire 
drum. 

The tendency in the former variety of opening is to too readily 
heal, closing before the discharge has ceased. 



DISEASES OF THE EAR 



171 





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172 THE DISEASES OF CHILDEEN 

Prognosis. The earlier this condition is recognized and 
properly treated the better the chances of recovery with normal 
hearing. Continuance of fever and other symptoms after dis- 
charge has begun indicates an involvement of deeper structures 
as the mastoid and the brain. 

Untreated cases develop into a chronic condition with con- 
tinuous discharge, washing away of the entire drum, frequently 
evacuation of the ossicles and permanent deafness. 

Treatment. The indications for treatment as soon as diag- 
nosis is established are very clear ; prompt and efficient drainage 
should be established as early as possible, and maintained, and 
extension of the inflammatory process stopped if possible. 

The local application of heat, continuous irrigation with hot 
saline solution for 10 or 15 minutes, or perhaps the administra- 
tion of an anodyne may be needed for the relief of the pain. 
In some cases leeches can be employed Avith advantage, but 
the child should not be allowed to see them or told what is 
being done when they are applied. As soon as a bulging of the 
drum has been diagnosed a free incision should be made, and, 
as suggested in the previous chapter, this should not be done 
except under a general anesthetic. It is a most painful opera- 
tion ; a view of the drum cannot be satisfactorily obtained with- 
out it, and if done without, and great pain caused, the child 
will be intolerant of examination and treatment for years after- 
ward. Early evacuation of the pus by paracentesis limits the 
chances of extension of the process to deeper structures from 
pressure of the pent-up secretion. 

Frequent examination of the drum should be made after para- 
centesis to note the changes occurring in the drum, the tendency 
of the opening to close, etc. 

The patient should be confined to bed during the active stage 
of inflammation. The child should have a pledget of cotton in 
the external auditory canal and a pad of gauze covering the 
entire external ear, this confined by a bandage over the head. 

Lying with the affected side down is a great aid in drainage. 



DISEASES OF THE EAR 



173 



Frequent irrigation i? of great benefit, at least every three hours 
at first. 

The following table given by Bamhill gives excellently the 
differential diagnosis of the three forms of trouble just 
described : 



DIFFERENTIAL DIAGNOSIS OF ACTTTE TITBOTYMP-ANIC CATARRH. ACUTE CAT.^JIRHAL 
OTITIS MEDIA. AND ACUTE SUPPURATIVE OTITIS MEDIA. 



Acute Tubotympanic 
Catarrh. 

Absent irr the ear; usu- 
ally amounts only to 
a sense of soreness in 
throat, as of foreign 
body. More or less 
pain along course of 
Eustachian tube. 



Acute Catarrhal Otitis 
Media. 

P-UN. 

Severe in depths of the 
ear, radiating over 
side of head. Worse 
on hing down. Pain 
increased by blowing 
nose or coughing. 



Acute Suppurative Otitis 
Media. 

Very severe, of lancinat- 
ing, tearing variety. 
Increased by recumb- 
ent position, by cough- 
ing, sneezing, blowing 
of the nose. etc. 



Absent, unless the tubo- 
tympanic catarrh is 
secondary to some 
other ailment as a 
mild form of measles, 
which primary disease 
gives rise to the fever. 



fe^t:r. 

Temperature usually 
elevated, 100° F. in m- 
fants and young chil- 
dren. 



Ranges from 102 to 104° 
F., the height of tem- 
perature depending 
much upon the pres- 
ence of some general 
disease, as measles. 
scarlet fever or la 
grippe. 



Moderate. Patient com- 
plains of great deaf- 
ness, however, largely 
because of the sudden- 
ness of onset. 



deafness 
Verj' considerable in af- 
fected ear. 



Verj' great in affected 
ear. Patient ver\' 
deaf when both ears 
are involved. 



None. 



PROSTRATION OF PATIENT 

Usually moderate. Often verj- great. 

Sometimes consider- 
able. 



174 



THE DISEASES OP CHILDREN 



Present and often severe. 



Greatly retracted in first 
stage, less so in second 
stage. Inflammation 
absent, vessels along 
handle of malleus 
sometimes injected. 
After exudation into 
the tympanic cavity 
has occurred, a dark, 
or sometimes a light 
line may be seen cross- 
ing membrane, and in- 
dicating level of fluid. 
All landmarks pres- 
ent. 

Drum membrane seldom 
ruptured. 



None except after para- 
centesis. 



Rarefied in first stage. 
In second stage fre- 
quently contains a 
yellowish serum, or 
ropy, mucoid exudate, 
which is visible 
through non-inflamed 
membrana tympani. 



TINNITUS, VERTIGO, ETC. 

Head noises not a prom- 
inent symptom ex- 
cept in later stages, 
after the pain and 
fever have subsided. 
Vertigo and nausea 
rare. 

DRUM MEMBRANE. 

Little or not at all re- 
tracted at onset, later 
is bulging over some 
quadrant. Injected at 
first, and later a dif- 
fuse, uniform redness 
covers whole mem- 
brane. Landmarks 
usually all obliterated 
with possible excep- 
tion of short process 
of the malleus. 



PERFORATION 

Drum membrane usu- 
ally perforated after 
from one to three days 

DISCHARGE. 

Thin, seromucous dis- 
charge immediately 
after rupture or para- 
centesis. May later 
become purulent from 
infection. 

TYMPANIC CAVITY. 

Contains seromucous 
exudate, which bulges 
membrane, but is not 
visible through in- 
flamed membrane. 



If present in beginning 
are so masked by 
severe pain that they 
are not mentioned. 
Sometimes present 
during convalescence. 



Intensely reddened, es- 
pecially in upper por- 
tion; swollen, bulging, 
opaque. Landmarks 
all obliterated. Drum 
membrane may be 
largely destroyed dur- 
ing first two or three 
days. 



Always present after 
two or three days. 



Sanguinopurulent at mo- 
ment of perforation, 
purulent 4ater. Usu- 
ally very profuse. 



Contains pus. Mucous 
membrane greatly 
swollen, with necrotic 
areas in worst cases. 
Incus and hammer 
sometimes carious. 



DISEASES OF THE EAR 



1?5 



Not painful. Immedi- 
ate and marked im- 
provement results to 
hearing. 



TYMPANIC INFLATION. 

Painful. Little or no 
improvement in hear- 
ing except in later 



Painful and should sel- 
dom be performed 
during height of in- 
flammation. 



Usually accompanies or 
follows a cold in the 
head or a naso-phar- 
yngitis. May result 
from mild attacks of 
exanthemata or ton- 
sillitis. 



Never occurs. 



Accompanies or follows 
the exanthemata of 
moderate severity, 
and the acute tonsil- 
lar and naso-pharyn- 
geal inflammations. 

MASTOID COMPLICATION. 

Seldom occurs. 



Follows or accompanies 
the more violent 
forms of the exanthe- 
mata, la grippe, ulcer- 
ative tonsillitis, diph- 
theria, etc. 



Frequently occurs. 



MASTOIDITIS. 

The mastoid is but poorly developed in young infants, and 
fortunately not so very frequently involved as later in childhood. 

Etiology. Probably less than 1 per cent of cases of mastoid- 
itis develop without being secondary to acute suppurative mid- 
dle-ear disease. E'eglected cases of suppuration with long- 
retained pent-up secretion in the middle ear makes infection of 
the mastoid cells an easy matter. 

Diagnosis. This is not always easy, and many factors influ- 
ence one in an opinion as to its involvement. It should be 
suspected in all cases of severe and prolonged suppurative, 
middle-ear cases. Constitutional symptoms are apt to be more 
severe upon the development of mastoiditis, temperature more 
elevated, pain more acute, local symptoms over the mastoid 
develop. 

Symptoms. A previously free discharge may cease or become 
much lessened, the temperature usually rises quite high, or the 
patient may be entirely or practically afebrile. The pain or 
-discomfort and tenderness are quickly located behind the ear, 
which is shortly follow^ed by a swelling of the skin just back 
of and slightly below the middle point of the back of the ear. 



176 THE DISEASES OF CHILDREN! 

"A sagging of the posterior superior meatal wall" has been 
suggested as a fairly constant occurrence. 

Prognosis. This condition is an extremely serious one and 
causes great anxiety on the part of the physician or specialist 
in charge. The decision as to employment of surgery is difficult 
to make and requires keen observation and thought. 

Treatment. Local application of cold over the affected 
antrum by cloths, small ice bags or specially-devised ear ice 
bags is first indicated, or the opposite, heat, may be equally 
effective in reducing inflammation and easing pain. Sedatives 
may be positively necessary but should be used with great cau- 
tion and conservatism. Leeches to the affected side may be 
serviceable if applied early in the involvement. 

As before stated, just where the medical treatment fails 
and surgery is indicated is a fine line not easily differentiated, 
and it is a safe rule to follow, when in doubt operate. 

A competent specialist should always be associated with the 
practitioner in these cases. 



CHAPTER X. 

Diseases of the Eye. 

Eyestrain. The prevalence of eyestrain in school children 
is but little appreciated by teachers, parents or physicians. The 
eyesight should be systematically tested in all school children 
by a medical examiner, and the parents of those found deficient 
notified and requested to have the defect corrected. 

Statistics of different observers^ show from 30 to 50 per cent 
of several thousand school children, systematically examined, 
to have visual defects, and could use glasses for close work with 
benefit to their eyes. It was found an average of 11 per cent 
of school children wear glasses. Investigation in 20,000 cases 
showed that 7.3 per cent of all children suffer from 6/18 or 
worse defective vision. Of the various errors of refraction the 
following table shows the result in~ 2500 Philadelphia school 
children of all grades: 

Per cent. 

Emnietropia 11 . 19 

Hyperopia, simple 31.23 per cent \ 74 04 

with Astigmatism 42 . 81 per cent | 
Myopia, simple 2 . 68 per cent \ 1 o yn 

with astigmatism 11 . 02 per cent / 
Mixed astigmatism 1.07 

Headache, fatigue, inability to concentrate the attention or 
to study result from eyestrain, and a careful examination should 
be made in all cases. 

BLEPHARITIS. 

Definition. An inflammation of the margin of the lids which 
is quite frequent in children. 

*rornpll. Monthly Cyclopedia of Practical Medicine, March 1908. 

177 



l78 THE DISEASES OF CHILDREN 

Etiology. An infection of tlie hair follicles is usually the 
beginning of the process. The squamous and ulcerative types 
are recognized. Predisposing causes are eyestrain, dust and 
smoke which result in a congestion of the mucous membrane 
of the lids. The exanthemata and a general run-down condi- 
tion also predispose to it. It is usually found in connection 
with conjunctivitis, both catarrhal and phlyctenular, and often 
with eczema of face. 

Symptoms. In the milder form there may not be many focal 
symptoms beyond a scaliness of the edge of the lids, which carry 
away a few hairs when brushed off. In acute cases there is a 
burning and itching sensation of the margin of the lids and 
some photophobia; after a duration of some days the edges of 
the lids are much congested and swollen and bathed in a thick 
yellowish secretion. 

Treatment. In the squamous form after removal of the 
scales, which can be accomplished by washing with an alkaline 
solution and soap, or softening with vaseline, the local treat- 
ment can be begun. The following can be used to advantage : 

1^1 Hydrargyri oxidi flav. gr. viii 

Vaselini 5i 

M. ft. ung. 

In the ulcerative form they may need the application of a 
1 or 2 per cent solution of nitrate of silver after removal of 
concretions. Generally a tonic treatment is indicated with 
proper hygienic surroundings. 

HORDEOLUM. 

Synonym. 8tye. 

Etiology. An infection of one of the glands of the eyelid 
or an eyelash follicle takes place from an invasion of the staphyl- 
ococcus aureus or other pus-producing organism. As a result 
of the inflammation suppuration takes place, and frequently a 
reinfection results with a succession of them. As predisposing 



DISEASES OF THE EYE 179 

cause, blepharitis marginalis is perhaps the most frequent. Eye- 
strain is also a predisposing cause. 

Symptoms. Pain of a stinging or smarting character and 
edema of the lid precedes the development of the stye. The 
"pointing" of the abscess is usually at or near the lid margin, 
and it may rupture spontaneously or necessitate an incision to 
evacuate the pus. The pus is usually quite thick and stringy 
in character. 

Styes may develop in quite young children, and when it is 
considered how possible it is for an infection to take place in 
the child as it plays upon the floor and rubs its eyes with its 
fists it is a wonder they are not oftener seen. I have seen one 
in an infant of six months, recently. 

Treatment. The abortive treatment is occasionally success- 
ful, viz. : Cold applications and pulling out a lash when root 
is infected, or the application of a 30-grain-to-the-ounce solu- 
tion of sulphate of zinc. If the upper lid is affected, it is pulled 
down over the lower lid and the solution painted over its edge 
with a cotton-covered match or tooth pick. The solution is not 
allowed to touch the conjunctiva of the eye. The applications 
are repeated several times during the day. 

The injection of carbolic acid to abort the boil cannot be even 
considered in the child. 

If a blepharitis marginalis is present the use of a yellow 
oxide of mercury ointment (gr. ii to Si) may bring about a 
cure promptly enough to prevent a stye from forming. 

If the edema continues and the collection of pus does not 
take place quickly, much relief can be had by the application 
of poultices, small squares of flannel wrang out of hot water 
and laid over the affected eye. As soon as pus formation is 
assured, it should be evacuated with a triangular knife. The 
hot applications should be continued while there is a free flow 
of pus, and this followed by the yellow oxide ointment. 



180 THE DISEASES OF CHILDREN 



CONJUNCTIVITIS. 



Two varieties may be seen, simple catarrhal conjunctivitis or 
tlie epidemic or contagious conjunctivitis, tlie latter being called 
pink eye. 

Etiology. This is due to the invasion of the conjunctivae with 
bacteria, the pneumococcus and the Weeks bacillus being most 
frequently the cause. Bacteria-laden dust may be the active 
cause. Common use of towels is a frequent manner of dis- 
semination. 

Symptoms. The simple catarrhal form is much milder in all 
its symptoms, and in its duration also. There is a burning and 
smarting of the eyes and lids, and a feeling as if something 
w^ere in the eye and that the lids must be rubbed frequently. 
There is early and profuse lacrimation, and the lids are stuck 
together when the child awakens. 

There is an injection of the entire conjunctiva and the lid 
mucous membrane is frequently much swollen. When the lids 
are everted the conjunctival surface will be found covered with 
mucus. It is rare that only one eye is affected. 

Treatment. Much can be accomplished by local treatment. 
The eyes should be irrigated twice daily with a warmed 3 per 
cent solution of boracic acid, and one or two drops of the fol- 
lowing solution dropped into each eye three times a day : 



I^ Zinci sulphatis 


gr. ss 


Acidi boracici 


gr. X 


Aquae comphorat. 




Aquae destillat. 


aa OSS 


ft. sol. 





A mild boracic acid ointment is rubbed into the lids each night 
or before the child is put to sleep during the day in order to 
prevent the troublesome matting together of them. 

Protection from strong light and w^nds should be insisted 
upon also. 



DISEASES OF THE EYE 181 



TRACHOMA. 



A chronic infectious, inflammatory condition of the palpebral 
conjunctiva, with the formation of oval masses in the membrane. 

Etiology. This disease is much more frequent in children, 
though no age is exempt. Unhygienic surroundings, filth and 
improper food predispose to it. The specific organism has not 
been isolated, though a small double coccus has been described 
by Sattler, and a fungus by Muttermilch. The latter has been 
termed microsporosa trackomatorum. 

Pathology. At first there is a minute granular hypertrophy 
of the mucous membrane of the lid conjunctiva without involve- 
ment of the eye conjunctiva or cornea. There follows a deep 
injection and thickening of the mucous membrane and develop- 
ment of the larger granular masses ox follicles, which are minia- 
ture lymph glands. After a varying length of time there fol- 
lows the stage of cicatrization. The granules coalesce, small 
cicatricial bands appear, the area of conjunctival surface is less, 
the roughened lids scrape the eye and ulcers of the cornea form. 
Trachoma occurs with rarity in the negro. 

Symptoms. During the first of the granular stage there may 
be no symptoms. There is little or no discharge, and the lids 
do not adhere in the morning. After the granules have formed 
there is pain in the eyelids and a feeling as if sand Avere in the 
eyes, discharge is profuse, mucopurulent in character, photo- 
phobia is present and swelling of the lids take place. At this 
time the ocular conjunctiva becomes injected. The lids are 
everted with difficulty owing to the swelling of the mucous mem- 
brane. These acute symptoms may subside spontaneously, and 
the condition develop into a more or less chronic one, with 
slight lacrimation and mucopurulent discharge. The glands 
at the angle of the jaw and behind the ear may become enlarged. 

Prognosis. Even under proper treatment the prognosis is 
not very good. It is essentially a chronic condition, relapses 
are frequent, even in the apparently cured. 



182 THE DISEASES OF CHILDREN 

Sequelae. Opacities and pannus of the cornea; entropion and 
ectropion; disticliiasis and symhlepharon. 

Treatment. Prophylaxis is of the greatest importance. In 
institutions, children with trachoma should be quarantined. 
Shower baths should be installed in all institutions, as the 
bathing of several in one tub, as frequently will occur if tub- 
bathing is practiced, may be the cause of its dissemination. Indi- 
vidual towels, handkerchiefs and beds should be insisted upon. 

Since the introduction of the newer silver salts, protargol has 
been recommended as giving good results in the acute stage. 
Every other day a 40 per cent solution is painted over the dis- 
eased surface, and a 10 per cent solution instilled into each eye 
twice daily. Other remedies suggested are the following : Solu- 
tion of bichloride of mercury (1:5000) painted on the lids and 
1:15,000 as eyedrops; formalin (1:3000), and the application 
of sulphate of copper crystal direct to the diseased surface. 

Surgical treatment consists in the use of the roller forceps, 
under general anesthesia. 




FIG. 35. ROLLER FORCEPS FOR TRACHOMA. 
GBAJSTULAR CONJUNCTIVITIS. 

A much milder form of conjunctivitis than trachoma may be 
encountered in which there is a deposit of very fine granules in 
the conjunctiva. 

The symptoms and course are much less severe, and the dura- 
tion shorter. 

Treatment. The response to treatment is usually much more 
prompt in this variety. Tlie silver salts are efficient and bring 
a speedy cure if properly applied. They are used the same as 
in trachoma. 



DISEASES OF THE EYE 183 

VEEXAL CATAKEH OF THE COXJUXCTIVA. 

This form of conjunctivitis has recently been recogTiized by 
the authorities. 

It is frequent in children during the summer months, and 
consists of a lymphoid hypertrophy of both the palpebral and 
ocular mucous membrane, and especially around the cornea. 

It is intractable, has a tendency to recur and passes away, 
often uninfluenced by treatment, as the summer heat disappears. 

DIPHTHERITIC COXJUXCTITITIS. 

Etiology. The Klebs-Loeffler bacillus is the cause of this 
form of conjunctivitis, but it rarely exists alone, being com- 
plicated by other pus-producing organisms, especially the strep- 
tococci and staphylococci. 

Pathology. The process in the conjunctiva as the result of 
the invasion of the Klebs-Loeffler bacillus is the same as in other 
mucous membranes. The formation of the pseudomembrane 
occurs within 24 hours after the first congestion. The super- 
ficial epithelia are destroyed and the pseudomembrane dips 
down into the conjunctiva, leaving a bleeding surface when it 
is detached. The ocular conjunctiva may be involved in the 
same process. 

Symptoms, Focal. There is a great swelling of the mucous 
membrane of the lids, with intense congestion. Lacrimation is 
not profuse at the first, the discharge is thick and blood tinged. 
Later the discharge becomes thinner and purulent. The pseudo- 
membrane forms in 24 or 36 hours. Bacteriologic examination 
may be needed to deteiTaine the exact nature of the condition. 

General. The child looks sicker than in any of the other 
conjunctival inflammations. There is an elevation of from 2° 
to 5° F. in the temperature. 

Treatment. As soon as a pseudomembrane is seen 2500 to 
3000 imits of antitoxin must be administered, without waiting 
for the result of the bacteriologic examination. The same rules 



184 THE DISEASES OF CHILDREN 

obtain here as to the second dose of antitoxin as in pharyngeal 
or tonsillar diphtheria. 

For great ecchymosis, cold application to the lids, and nitrate 
of silver solution, 1 to 1.5 per cent, to the conjmictivse after the 
removal of the membrane. 

Ulcer of the cornea is to be feared if the swelling of the lids 
is marked and pressnre very great. 

PHEYCTENULAE CONJUNCTIVITIS. 

Synonyms. Scrofulous conjunctivitis; eczematous conjunc- 
tivitis. 

Etiology. As indicated in the name given this disease, a 
marasmic, tnbercnlar or otherwise debilitated condition, pre- 
disposes to this form of conjunctivitis. It also follows or com- 
plicates blepharitis marginalis ; acute conjunctivitis, eczema of 
the face or lids. The staphylococcus aureus has been found in 
the fluid of the phlyctenule. It rarely occurs in adults. 

Pathology. The phlyctenules are nodules on the conjunctiva 
or cornea, formed by an accumulation of small cells on the base- 
ment membrane and pushing up the superficial epithelial cells. 
An enlargement of the blood vessels occurs and they radiate, 
spoke-like, from the phlyctenule. The surface of the phlyctenule 
or nodule softens and the contents escape, leaving a small ulcer 
on the conjunctiva or cornea. 

Symptoms, Focal. The principal symptoms are lacrimation 
and photophobia. There is some discharge which runs down 
upon the cheek and may cause an eczematous condition there. 
A nasal catarrh is present also. There is usually a character- 
istic pose in these cases, the child burying its face in the neck 
of mother or nurse, or holding eyes in bend of elbow. The 
appearance of the eye is described under pathology. 

General. The child looks run down, is pale and anemic, 
tongue is coated, and the digestion may be upset. 

Treatment. If the injection of the conjunctiva is very great 
a solution of atropia, 1 or 2 grains to the ounce of 50 per cent 



DISEASES OF THE EYE 185 

boracic acicl solution, may be instilled. An application of the 
yellow oxide of mercury ointment (gr. i to oi) is applied once 
or twice daily. A piece of the size of the end of a match is 
put between the lower lid and eyeball and the lid closed. Dry 
calomel may be applied, with advantage, to the ulcer when it 
forms. 

Generally, a tonic is always indicated in these cases. A solu- 
tion of the hypophosphites, glycerophosphates or cod liver oil 
will be of benefit. 

The diet should be regulated and much fresh air insisted upon. 
Study and use of the eyes should not be allowed. Dark glasses 
in the older cases will give great comfort. 

OPHTHALMIA, NEONATORUM. 

Etiology. Due to the entrance into the conjunctival sac of 
the gonococcus, having gained entrance during the passage of 
the head through the cervix and vagina. The colon bacillus or 
the pyogenic organisms may be the cause of a milder infiamma- 
tion. If it occurs in later life it is caused by the accidental 
inoculation of the eye with the gonococcus. 

Prophylaxis. The instillation into each eye of 1 drop of a 
2 per cent solution of nitrate of silver, followed by an irriga- 
tion of normal salt solution, will prevent ophthalmia. Its use 
should be universal and not reserved for those children whose 
mothers are suspected of having a specific vaginitis at the time 
of the labor. 

For those who prefer a substitute for the nitrate of silver, 
because of fancied irritation following its use, a 10 per cent 
argyrol solution is recommended. 

Focal Symptoms. Usually on the second or third day the lids 
of one or both eyes are stuck together, and when separated a 
profuse discharge escapes. The discharge is distinctly purulent 
and may run down on to the cheek. The lids rapidly become 
swollen and the mucous membrane intensely congested, making 



186 THE DISEASES OF CHILDREN 

it difficult to evert them. If the secretion remains pent up be- 
tween the lids an ulceration of the cornea may result. 

Great pain evidenced by crying and restlessness is present; 
there is marked photophobia, and unless the hands are pinned 
down the eyes will be rubbed. 

Prognosis. This form of inflammation is one of the most 
serious to be encountered. More cases of blindness result from 
a specific conjunctivitis than any other. Magnus reports that 
24 per cent of inmates of institutions for the blind in Europe 
have lost their sight from ophthalmia, and statistics show an 
equal or greater number in this country. Upon prophylaxis, 
and promptness of treatment alone, success depends. 

Sequelae. In the severe cases, as a sequence, the following 
conditions may be found : iVnterior staphyloma ; ulceration and 
necrosis of the cornea leaving an opacity which may seriously 
impair vision; or an anterior synechia. 

Case. In one of the few cases in my experience in which 
I failed to employ the Crede method of prophylaxis, an ulcera- 
tion of the cornea in both eyes followed a severe ophthalmia and 
an evacuation of the contents of both globes. In this case, an 
institution one, the silver was not used, as the bottle containing 
the solution was turned over and its contents lost. When it was 
used the next morning it was too late, as evidences of inflamma- 
tion were present. This one unfortunate case has been a con- 
stant reminder to use the silver in the eyes of every new-born 
baby. 

Treatment. Good results can be had only by beginning the 
treatment promptly; the treatment must be not only unremit- 
ting but intelligently prescribed and administered. To verify 
the diagnosis a smear of the purulent discharge should be made 
upon a slide, stained with methylene-blue and examined for 
the gonococcus. As the symptoms are so rapid in development 
the beginning of the treatment should not wait upon the micro- 
scopic report. 

A day and night nurse should be employed. The eyes should 



DISEASES OF THE EYE 187 

be irrigated with a boracic acid or normal salt solution once 
every hour in the 24. The first thought, if only one eye is af- 
fected, should be to prevent the infection of the other. The child 
lying upon the affected side with face held over a basin, the solu- 
tion is directed into the inner canthus of the affected eye, with 
the lids opened as far as it is possible. This irrigation should be 
gently done to avoid abrasion of the cornea, and the fountain 
syringe not held over 12 inches above the head. 

Between the irrigation, unless the secretion is thin and watery, 
the eye is kept covered with ice cloths. Cotton goods is cut 
into 1-inch squares, and these are kept attached to a block of 
ice in a basin near the bedside. As they are removed from 
the eye they are destroyed and fresh ones applied every 15 
minutes. This treatment has been objected to by some as it is 
thought to be impracticable to apply the cloths effectively, but 
they are of the very greatest benefit when properly applied. 

Silver solution in some form must be applied, nitrate of 
silver in a 2 per cent solution, or argyrol or protargol in a 40 
per cent solution, once daily. It is claimed for the latter 
solutions that they are more penetrating than the nitrate. The 
nitrate can be used in the morning and a weaker solution (10 
to 20 per cent) of argyrol two or three times during the day. 

If it is possible to do so the solution should be applied to 
the everted lids by a cotton swab, but this may be impossible 
on account of the great swelling of the lids. In this event the 
solution should be instilled as thoroughly as possible. 

To evert the eyelids of a child Yail^ recommends the fol- 
lowing method: 

The surgeon sits with the child's head lightly clamped be- 
tween his knees, the child's body in the lap of the nurse, sitting 
close by in a chair, and the child's hands held by the nurse. 
The feet are allowed to kick free. The entire finger nail of 
the left index finger is placed on the lower lid and the finger 
crooked so that the pulp of the finger tip will just override the 

* Journal of Ophthal. and Otolaryngology, December, 1907. 



188 THE DISEASES OF CHILDREN 

edge of the lower lid; then the upper lid is gently pnshed down- 
ward by means of the index finger of the right hand, placed 
at the upper tarsal rim, until the free border of the upper lid 
overrides the pulp of the finger tip of the left index. Main- 
taining the pressure with the right index finger when this posi- 
tion is effected, the upper lid is turned inside out by simply 
keeping the free edge of the upper lid against the pulp of the 
index finger of the left hand. The right hand is now free to 
use in everting the lower lid. Having everted the upper lid, 
the lower is easily everted by making pressure downward with 
the right thumb. 

The protection of the sound eye by a watch crystal held in 
place by adhesive strips has been recommended by Buller, and 
in older patients is practical. The hands of the infant should 
be held down by pinning the sleeves to the front of its dress. 

Regularity of feeding and tonic treatment, if case is pro- 
longed, is recommended. 

PTERYGIUM. 

This is an imcommon condition in children. It consists of 
a circumscribed hypertrophy of the conjunctiva, quite regularly 
triangular in shape, containing enlarged blood vessels, and the 
apex of the area pointing toward the cornea. The vessels enter 
at the base. 

Etiology. Two varieties are usually described, pseudopter- 
ygiu7n and true pterygium. In the first, the condition seems 
more like a formation of cicatricial bands following a violent 
inflammation such as a gonorrheal or diphtheritic conjunctivitis, 
or trachoma. The latter form has been ascribed to the long 
exposure of the eyes to heat, or the sun's rays, as on the water, 
wind, dust, etc. 

Symptoms. These growths usually occur on the nasal side 
of the eyeball, though the whole horizontal, central area of the 
ball may rarely be involved. The growth gives practically no 
]:»ain or inconvenience, but is very unsightly. 



DISEASES OF THE EYE. 189 

Treatment. Surgery offers the best results, and excision is 
the best method of dealing with it. 

Diseases of the Cokxea. 
phlyctezs ulae keeatitis. 

Etiology. The same conditions causing phlyctenular con- 
junctivitis cause a phlyctenular keratitis, and, in fact, they 
usually occur simultaneously. It occtirs most frequently be- 
tween the ages of 2 and 12 years. 

Symptoms. The same symptoms that are present in phlyc- 
tenular keratitis ; the photophobia and lacrimation are more 
severe. Accordiiiii' to the location of the ulcer is the sio-ht 
affected. If over or near the pupil the sight may be greatly 
impaired, owing to the opacity of the cornea. The pose referred 
to in the description of the conjunctival variety is more con- 
stantly maintained. The eyes may have to be forced open for 
inspection because of the photophobia. Lacrimation is profuse, 
and mucopus is present in most of the ca^es. When one or 
more phlyctenules are seen at the margin of the cornea, over- 
lapping both the cornea and conjunctiva, they are called mar- 
ginal phlyctenules. 

Treatment. Atropia instilled into the eye is very necessary, 
using, perhaps, a slightly stronger solution (gr. ii or iii to 51 ). 
The same strength of yellow oxide of mercury ointment, if of 
the same value, in this form. Boracic acid irrigations should 
be used three or four times a day. A general tonic treatment 
is also indicated. The photophobia may often be overcome by 
immersing the face in a basin of cold water for a few seconds 
several times a day. 

IXTEESTITIAL KEEATITIS. 

This is the form of inflammation of the cornea first described 
by Hutchinson as occurring in congenital syphilis. It occurs 
generally in children, and is most frequent between 5 and 12 
years of age. It is generally bilateral. 



190 I'HE DISEASES OF CHILDREN 

Pathology. There is an inflammation and infiltration of the 
cornea with formation of fine blood vessels deep in the corneal 
tissues, and an injection of the conjunctiva. The infiltration 
is uneven. There may be an opacity of the entire cornea. If 
recovery takes place there may remain some fine lines running 
through the cornea, which were the former vessels. 

Symptoms. There is lacrimation and photophobia but not 
much pain. Sometimes there is a spasm of the lids. Asso- 
ciated with this disease are the peculiar notched or Hutchinson 
teeth; the skin lesions occurring in syphilis; the facies, and 
labyrinthine deafness. 

The duration is chronic, recovery rarely occurring sooner 
than two or three years. Atropia is of great help in obtaining 
comfort and should be used for its effect two or three times 
daily in solution 3 to 4 grains to the ounce. In the very acute 
stage the patient may have to be placed in a dark room, but 
usually comfort can be had by use of dark glasses. Application 
of hot cloths is of great comfort, in presence of spasm of the 
lids. Difference of opinion exists as to the value of yellow 
oxide of mercury ointment. It should be used only when the 
severe inflammatory symptoms have subsided, and in connection 
with massage is of benefit. 

In the acute inflammatory stage atropin is used with the hot 
applications on account of the probability of an iritis developing. 

Internally mercury is indicated early and late and contin- 
uously for a number of weeks. Iron and cod liver oil are also 
important, in connection with good food. 



CHAPTEE XI. 

Foreign Bodies in the Bronchial Tubes. 

Owing to the frequency with which children place foreign 
bodies in the nose and mouth, the comparative infrequency of 
the aspiration of these bodies in the bronchial tubes is to be 
wondered at. Any small body may find its way into a bronchial 
tube, as a glass bead, a pea or bean, a pebble, etc. 

Symptoms. A child while at play, usually entirely well, is 
seized suddenly with a paroxysm of coughing, followed by 
dyspnea, which may be quite severe, there being a decided blue- 
ness of the face. If the object is of sufficient size to obstruct 
the larynx the child will succumb from asphyxiation; if it 
lodges in a bronchus, there may be no more than frequent repeti- 
tion of the paroxysmal coughing. Owing to the large size of the 
right bronchus, and the angle at which it arises from the trachea, 
these bodies usually lodge on this side. An X-ray examination 
may be necessary to locate the body.^ 

Physical signs may aid the diagnosis. If the obstruction is 
complete there is absence of the respiratory murmur and voice 
sounds on that side, though at first there may be resonance due 
to the retention in the vesicles of the air in the lung at the time 
of the obstruction. This air is soon absorbed and dulness is 
found over the entire lung. 

Owing to the irritation and bacterial invasion a broncho- 
pneumonia is very liable to develop, or a localized abscess. 

Diagnosis. With the history detailed above, the aspiration 
of a foreig-n body should always be suspected. The presence of 
a paroxysmal cough of very sudden onset without previous 
coughing is suggestive. A diagnosis from whooping-cough 
must be made, which should be easy, as whooping-cough does 
not begin as suddenly. 

191 



192 THE DISEASES OF CHILDREN 

Treatment. If the diagnosis is made as soon as the aspira- 
tion occnrs it may be dislodged by quickly grasping the child 
by the feet^ suspending it inverted and shaking it. If not at 
once thrown off the spasm produced in the glottis prevents its 
expulsion. 

The first procedure unsuccessful, tracheotomy can be per- 
formed at once, the edges of the wound held open by ligatures, 
and the child again inverted. Located by an X-ray through 
the tracheotomy wound, it can probably be grasped and re- 
moved by long, slender forceps. 

These are most serious cases and can be best treated in a 
well-equipped hospital. 



This is a condition in which a lobule or lobe of the lung is 
collapsed. It is principally found in new-born infants, though 
a collapse may occur at any time. 

Etiology. A plug of mucus inhaled by a new-born with its 
first inspirations may lodge in a bronchus leading to an alveolus 
and completely shut off the air from this part, followed by a 
collapse of that portion. The same condition may occur in 
bronchitis in later life, or after the aspiration of a foreign body 
into a larger bronchus. 

Patholog^y. There is a collapse of the alveoli of the lung, 
and may be limited to a small area singly or scattered through 
the lung. The affected areas are like liver in appearance, and 
are depressed below the general surface of the lung. There may 
be small areas of emphysema surrounding them. 

Symptoms. In the new-born there may be no physical signs 
or symptoms by which the condition can be recognized early. 
Later, if extensive, there is a sinking in of the chest on that 
side, or if scattered there may be no evidence of the condition 
except an impairment of the breath sounds over the affected 
area, with localized dulness, perhaps. 

In late cases, and extensive collapse, absence of breath sounds. 



FOREIGN BODIES IN THE BRONCHIAL TUBES 193 

harsh breathing, duhiess and collapse of the chest wall are diag- 
nostic points. 

Treatment. The prompt removal of mncns in the naso- 
pharynx of the new-born will prevent its aspiration into the 
bronchi, inversion of the child and obtaining free inspiration 
and crying aids in the dilatation of the bronchi and dislodging 
of dry mucus which may have been aspirated. 

In older children, when it follows bronchitis, a dose of ipecac 
for its physiological effect, the mucus being dislodged during 
vomiting, is efficient in dislodging obstructing plugs. Frequent 
spanking to make it cry and cause deep inspiration ; alternate 
hot- and cold-baths, for the effect of causing a shock to the skin, 
cause deep inspiration. 

ACUTE CATARRHAL BRONCHITIS. 

This is an inflammation of the mucous membrane of the 
bronchi, large or small, or both, with no involvement of the 
peribronchial tissue. 

Etiology. The primary and exciting cause is some micro- 
organism, as the influenzal bacillus, the strepto- and staphylo- 
cocci, etc. A dust-laden atmosphere, draughts, sudden ex- 
posures with chilling of the entire surface, and wet feet, may 
act as a direct exciting cause. It may occur secondarily to the 
acute exanthemata and to diphtheria, and is a frequent occur- 
rence in children who are the subject of adenoids and chronic 
nasopharyngeal catarrh. Children who are convalescing from 
acute attacks of diarrhea are prone to develop bronchitis, from 
lowered resistance. It is a frequent complication of whooping- 
cough, increasing the severity of this condition greatly. 

It occurs in rachitis and other nutritional disorders from a 
lowered power of resistance. 

Pathology. There is primarily a swelling of the mucous 
membrane of the larger bronchial tubes, with deep injection, 
followed quickly by a secretion which is largely serum at first, 
then mucopurulent as the disease progresses. It is usually 



194 THE DISEASES OF CHILDEEN 

bilateral and rarely in patches, even when the smaller tubes are 
involved. The inflammation is limited to the mucous mem- 
brane, and when it spreads to the peribronchial tissue the proc- 
ess becomes a bronchopneumonia. If there is a plugging of 
some of the smaller or capillary bronchial tubes the portion of 
the lung supplied by these tubes collapses. 

Symptoms. If there has been a primary tonsillitis or laryn- 
gitis, a low fever and slight cough precede the active symptoms 
of the bronchitis. It may begin as an acute coryza, with sneez- 
ing, discharge from the nose, and lacrimation. In mild cases, 
in which the process is chiefly limited to the larger bronchial 
tubes, there may be but few symptoms, malaise, slight rise in 
temperature, loss of appetite and cough. A child under five 
years of age, uninstructed, will swallow all mucus raised in 
coughing. 

In more severe cases in which the smaller tubes are involved, 
the child is acutely sick from the beginning. There may be 
vomiting; the temperature rises to 103° or 104° F., and with 
the development of the cough there is rapid breathing, with 
wide dilatation of the alse nasi. The dyspnea is frequently 
severe, and if any coryza exists it is difiicult for the child to 
nurse. This is especially true where there are nasopharyngeal 
adenoids. 

There is not usually a wide variation in the temperature be- 
tween morning and evening. There may be an evening drop 
and a morning exacerbation in rare cases. The temperature 
usually lasts four or five days, though it may last for a week. 
It is more easily controlled by hydriatic treatment than the 
fever of bronchopneumonia. 

The respirations are hurried, frequently as high as 80 per 
minute, and there may be a decided pallor of the skin of the 
face. When asleep the skin of the head is bathed in perspiration. 

The bowels may be disturbed, especially in young children, 
and the actions contain much mucus which has been swallowed. 

Physical Signs. Inspection of the bared chest shows in 



FOREIGN BODIES IN THE BRONCHIAL TUBES 195 

severe cases an employmeiit of the extraordinary muscles of 
respiration, and if there is much spasmodic contraction of the 
bronchial tubes a recession of the suprasternal and clavicular 
notches. 

Palpation of the chest in the first stage may be negative, but 
during the second stage when there is a secretion of mucus and 
niucopus, bronchial fremitus is easily felt, owing to the thin- 
ness of the chest walL For this reason and because of the large 
tubes, percussion is of little assistance as a diagnostic measure 
in this and some other of the pulmonary diseases of childhood. 

In the first stage, before secretion has occurred, auscultation 
reveals sonorous rales if only the larger tubes are affected, and 
sibilant rales when the smaller tubes are involved. These rales 
are general in distribution, but heard loudest at the apex. With 
the advent of the second stage on the second or third day, with 
mucus thrown out, moist rales are heard. They are large and 
small according to the lumen of the tube involved. If coughing 
occurs when auscultation is being performed, a small area of 
lung may be found free from rales entirely for a short while. 

Through the rales may be heard the normal vesicular breath- 
ing, though over the suprascapular and interscapular regions 
the vesicular sound is replaced by a harsh, high-pitched expira- 
tory sound simulating bronchial breathing. This fact should 
be borne in mind. 

Diagnosis. The principal diagnosis is from a hroncho- 
pneumonia, which may not be possible clinically. A localiza- 
tion of the physical signs of bronchitis and a continuation of 
the above symptoms beyond four or ^yq days is a very sug- 
gestive condition. Dulness over a limited area is also suggestive 
of consolidation or collapse of a more or less large area of lung. 

Prognosis. Older children with acute catarrhal bronchitis 
usually recover promptly in four to five days ; in infants, imtil 
entire subsidence of symptoms the condition should be con- 
sidered serious, because of the possibility of an extension of the 



196 THE DISEASES OF CHILDKEN 

process through the thin bronchial wall and the development of 
a bronchopneumonia. 

In the secondary cases, especially following measles, the prog- 
nosis should always be guarded. 

Treatment. The child should be kept in one room, if pos- 
sible, heated by an open fireplace, with windows open at the 
top and the temperature kept as evenly as possible at between 
60° and 65°, never as much as 70° F. The patient should be 
kept in bed, and several times a day a tent made over it with 
a sheet and the air impregnated with moist air from a so-called 
croup kettle or steam spray, which can be medicated with ben- 
zoin or eucalyptus. 

But little internal medication should be given, beyond a 
preliminary calomel purge. Frequent doses of syrupy cough 
mixtures have no place in the treatment of bronchitis. 

During the first stage the following tablet is of decided 
benefit : 

I^ Tartar emetic 

Powd. ipecac aa gr. 1-100 

Sacch lactis q. s. 
M ft. Tablet No. 1. 

These may be given every two hours to a child a year old, 
unless vomiting occurs. Dover's powders in small doses, gr. ^ 
or ^, or codeine sulphate, gr. ^ or ^, may be given when the 
child is put to bed for the night, if the cough is so persistent 
as to prevent its sleeping. In the presence of a sensation of 
tickling in the throat, adding to the cough, the application of 
a cold, wet compress to the neck, protected by a wide, dry 
flannel, is of great benefit. 

Counter irritation of the chest is of the greatest benefit, mus- 
tard plaster giving the best results. One part of Coleman's 
powdered mustard is mixed with 6 or 8 parts of fiour into a 
thick paste with cold w^ater, spread between two thin layers 
of cloth, warmed before the fire and applied to the skin. An 
edge is lifted from time to time to ascertain the depth of the 



FOREIGN BODIES IN THE BRONCNIAL TUBES 197 

redness of the skin. When the skin is quite red the plaster is 
removed and the surface greased with vaseline. Enough paste 
should be mixed to make two plasters, which are applied back 
and front at the same time. They are very soothing, as a rule, 
to a restless, dyspneic child, until they begin to bum, and helps 
the cough. They should be reapplied wdien the skin is pale 
enough to allow it, probably as often as every four hours. With 
scanty urine, a teaspoonful of liq. ammon. acetatis in w^ater 
every three or four hours is of benefit. 

Stimulating expectorants can be given older children when 
the secretion has changed, as 



I^ Ammon carbonat 


OSS 


Vin ipecac 


oil 


Syr. laurecerasi 


'oss 


Aquae dest. q.s. ad 


5ii 


M. ft. Sol. 




Sig. One teaspoonful 


every three hours. 



Prophylaxis is of the greatest importance. Children subject 
to lymphatism with adenoids and enlarged tonsils, should, in 
the spring or summer, have these removed. The importance 
of fresh air should be emphasized ; children should not be started 
to school under seven years of age. They should have a daily 
morning bath, followed by a cool sponge and a brisk rub until 
a vigorous reaction is obtained. The cold spinal douche is a 
great shock and not well borne by the average child. 

The sleeping of the child out of doors should be encouraged, 
the only consideration being that it be protected from draughts 
and wind. 

The sleeping room at night should preferably not have been 
used during the day, and if it has, should be thoroughly aired 
before the child is put to bed. The temperature should not be 
above 65° F. 

The barbarous custom of ''hardening" a child by keeping it 
without shoes or stockings at all seasons is responsible for many 
of these attacks. 



198 THE DISEASES OF CHILDREN 

Older children in colder climates should wear nnder- 
drawers as soon as bladder control has been established, as 
there is always a space from stocking top and drawers entirely 
uncovered. 

CHROlSriC CATARRHAL BRONCHITIS. 

This affection is a direct sequel of an acute bronchitis and 
occurs in older children who are the subject of nutritional dis- 
orders, as rachitis, lymphatism or organic heart lesions, syph- 
ilis, etc. 

Pathology. There is a chronic thickening of the mucous mem- 
brane, and numerous patches of dilated bronchi constituting 
either a local or a general emphysema. The mucous membrane 
is bathed with mucus and mucopurulent secretion. 

Symptoms. Cough is the principal symptom, and this is fre- 
quently more distressing at night; expectoration in older chil- 
dren is sometimes profuse ; the cough may be paroxysmal ; 
dyspnea is often present; usually there is a very slight rise in 
temperature, not often more than 100°. There is pallor and a 
clammy skin, the child is listless and has very little endurance, 
showing little tendency to exercise or exhibiting great fatigue 
with an increase of coughing on exertion. 

Physical Signs. On inspection there is noticed a tendency to 
bulging of the intercostal spaces from the emphysematous 
condition. 

Percussion shows an exaggerated resonance over the whole 
pulmonary area. 

On auscultation the respiratory murmur is feeble, and numer- 
ous dry and moist rales, large and small, are heard, displaced 
on coughing. 

Diagnosis. The chief differential diagnosis is from pul- 
monary tuberculosis. In chronic bronchitis the physical signs 
are general, the temperature not apt to be as high, the wasting 
not as rapid, the expectoration more profuse. 

Prognosis. In children the subject of lymphatism, the prog- 



FOREIGN BODIES IN THE BRONCHIAL TUBES 199 

nosis is not very good. If the cough is relieved on the advent 
of summer the prognosis is better. It is rendered worse by the 
development of any intercurrent disease. 

Treatment. Nothing is of so much avail in these children as 
a change in climate^ even though it be slight. Removed in the 
winter to a warm, salubrious climate, free from dampness and 
winds, in the pine regions, is of the greatest benefit. A place 
must be chosen where the child can live out of doors. The east 
coast of Florida, the Gulf coast along Alabama and Mississippi 
shores, or the pine regions of ^orth and South Carolina. This 
change should be made in the late fall before an attack. 

Forced feeding where this is possible yields excellent results, 
eggs and milk forming the basis of the extra diet. Sweets of 
all description should be denied rigorously. Cod liver oil gives 
the best possible results, administered pure, 15 to 30 drops 
after eating, if possible. 

Iron in an easily assimilable form is of benefit. 

I^ Tinct. ferri chloriri 5iss 

Glycerine ~ 3 ss 

Aquae dest. q.s. ad §iii 

M. Sig. One teaspoonful diluted after eating. 

EMPHYSEMA. 

This condition is a dilatation of the air vesicles and is asso- 
ciated with bronchiectasis, where the larger and smaller bron- 
chial tubes are dilated from a long-standing chronic inflamma- 
tion of the bronchial mucous membrane. 

Etiology. It is a frequent accompaniment of chronic bron- 
chitis, and occurs as a complication of whooping-cough from the 
violence of the straining during the paroxysms of coughing. 

Pathology. There is a weakening of the walls of the bronchi 
and air vesicles from chronic congestion and frequent violent 
stretching from coughing. When limited to the air vesicles it is 
usually termed vesicular emphysema, and in this event the 
symptoms are much more severe. The bronchial tubes and 



200 THE DISEASES OF CHILDREN 

vesicles are capable of acute dilatation without serious permanent 
damage^ and in such conditions as whooping.-cough the resiliency 
of the walls of the tube may overcome the dilatation as the 
disease subsides. 

Compensatory Emphysema always is found in the over-worked 
portion of the lung in pneumonia, and in the unaffected side 
in pleurisy, with effusion or atelectasis. 

The lung is dilated, the diaphragm displaced downward and 
the chest wall bulging to accommodate them. In the severe 
form there is a breaking down of the intervesicular walls and a 
coalescence of the vesicles. 

Symptoms. In cases of chronic bronchitis in which the breath- 
ing is specially labored, and there is noticed a change in the 
contour of the chest, emphysema should be suspected. There 
is a tendency for the chest to assume the barrel shape, the veins 
of the skin enlarge, dyspnea is a frequent early sig-n, and the 
least exertion causes fits of coughing which are more than 
usually severe. The heart is dilated and its action often rapid 
and tumultuous. 

Expectoration is usually profuse, especially on awakening, 
and there ^ may be nausea with a severe paroxysm of coughing. 

There is a marked increase in pulmonary resonance and a 
feeble respiratory murmur, which has lost its vesicular quality. 
Vocal fremitus is much lessened and the cardiac area of dulness 
much smaller owing to the overlapping of resonant lung. 

Rales are generally present and other signs of bronchitis. 

Treatment. This is largely symptomatic ; eliminate the cause 
when possible. When assaciated with bronchitis this must be 
relieved, the best results being obtained by a change of climate. 
The cough, of itself increasing the trouble, should be controlled 
by the administration of a pulmonary sedative: Codeine sul- 
phate, gr. -| to J, to child of three or four years, or heroin hydro- 
chlorate, gr. ^2" to 2V • General tonics are of the utmost 
importance, fresh air, good, nutritious diet, elimination of 
sweets entirely. 



FOREIGN BODIES IN THE BRONCHIAL TUBES 201 

Close watch must be kept on the bowels, as constipation is 
present as a rule and aggravates the condition. Regular enemas, 
cascara aromaticj 10 or 15 drops in water at bedtime. 

BRONCHOPNETJMONIA. 

Synonyms. Bronchial pneumonia; lobular pneumonia; capil- 
lary bronchitis. 

This is an inflammation of the bronchial mucous membrane, 
the peribronchial tissue and the air vesicles. 

Etiology. AVhen secondary to an acute or chronic bronchitis, 
there is an extension through the mucous membrane of the 
bronchi and air vesicles, of the inflammatory process. It may 
be secondary to the acute exanthemata or diphtheria, the toxins 
and organisms themselves setting up the process. 

It may occur entirely independent of any kno^vn disease as 
an acute primary condition, due to any of the organisms causing 
inflammation finding lodgment in the lung. The following 
organisms have been localized from bronchopneumonia, pneu- 
mococcus, staphylococcus, streptococcus, Klebs-Loeffler bacillus, 
bacillus coli communis. 

Pathology. The process may involve a single lobe of the 
lung, a more or less superficial area of the posterior portion or 
a small spot at any place, frequently on section a number of 
small areas of consolidation will be found, with smaller areas 
of atelectasis, and patches of emphysema nearby. The cut sur- 
face is dark and mottled and frothy mucus or mucopus oozes 
from the severed bronchi. ^Mien the consolidated spot is near 
the surface there is always an involvement of the pleura. This 
area is roughened and covered with fibrin. There may be 
adhesions between the two pleural surfaces. 

The bronchial glands are usually considerably enlarged. 

Prognosis. The prognosis in bronchopneumonia is not nearly 
so favorable as in lobar pneumonia. Primary bronchopneu- 
monia is less fatal than secondary, such as may occur as a com- 
plication of the exanthemata, pertussis, diarrhea, diphtheria, etc. 



202 THE DISEASES OF CHILDREN 

Dunlop* reports 333 cases of bronchopneumonia occurring 
in the Sick Children's Hospital, with a mortality of 28 per cent. 
The prognosis is influenced by the following conditions: Age, 
worse in the very young; the extent of the lung involvement, 
being bad in extensive involvement ; previous health, bad, when 
previous health has been poor, and when there have been nutri- 
tional disorders, as rickets, or a gastrointestinal disturbance. 

Symptoms. Primary bronchopneumonia usually begins sud- 
denly, much like lobar pneumonia, in fact the pathologic change 
in the lung is practically the only means of diagnosis. 

In severe cases the attack is usually ushered in with vomiting, 
there is a cough, though this is not always a prominent symptom. 

Dyspnea and hurried breatJiing are prominent and early 
symptoms. The temperature is irregular, not running persist- 
ently high as in lobar pneumonia; it may reach 104° F. but is 
usually below this. The pulse is accelerated and the respirations 
hurried ; the ratio is usually 2 to 1 or even 3 to 1. The expira- 
tory grunt may be present, but not with the same regularity as 
in lobar pneumonia ; there is dilatation of the alse nasi, and there 
may be more or less cyanosis. There is restlessness and 
prostration. 

If the pneumonic condition arises as a secondary disease there 
is an evidence at once that the child is sicker than it has been 
for a few days; the respiration and pulse are hurried, the 
temperature rises, cough becomes persistent and harassing. The 
cough is dry and, except in older children when secretion is 
profuse, there is no expectoration. 

The dyspnea causes restlessness at night and the cough ser- 
iously interferes with sleep also. The skin is generally more 
moist than in lobar pneumonia, often severe perspiration is 
seen, though it may be hot and dry. The cheeks do not have 
the deep red color as in lobar pneumonia, but are more cyanosed. 

There may be marked nervous symptoms, but convulsions in 
the onset are rare. The bowels are not as a rule disturbed, 

* British Medical Journal, August 15, 1908. 



FOREIGN BODIES IN THE BRONCHIAL TUBES 203 

though there may be a diarrhea. The actions are thinner as a 
rule than normal and may contain mucus. 

Physical Signs. isTo two cases of bronchopneumonia present 
the same physical signs. These may vary from the signs of a 
localized bronchitis to a frank consolidation, limited to a small 
area or involving the most of a lobe. 

Inspection reveals hurried respiration, pallor, dilatation of 
the alse nasi, recession of the suprasternal, supraclavicular and 
intercostal spaces, but without wide range of motion of the 
chest, owing to the emphysematous condition of the lungs. 

On percussion there is an increased pulmonary resonance 
over all except the consolidated area, due to the emphysema. 
Even the dulness, found usually over the consolidated area, is 
much diminished on this account. Owing to the thinness of the 
chest wall of the infant, percussion is not as valuable a means 
of physical diagnosis as in older children and adults. 

Palpation may reveal ronchial fremitus and if the consoli- 
dated area is large vocal fremitus may also be felt. 

Auscultation is of the greatest help in making a diagnosis. 
As before stated, the signs of a localized bronchitis are very 
suspicious. These may be the only signs heard which are suf- 
ficient for a diagnosis, when taken in connection with the other 
symptoms. 

Over the anterior chest but little may be heard, unless some 
consolidation appears here. Owing to the emphysema, the respi- 
ratory murmur is enfeebled. Over the posterior aspect, espe- 
cially^ every variety of rale may be heard, with areas over which 
pleuritic friction sounds are heard. The breathing is usually 
high-pitched, especially expiration, if not entirely bronchial in 
character. Voice sounds are increased and the sounds of the 
cry is exaggerated very much over this area. 

Cases may be much prolonged in their convalescence, the 
general symptoms subside, but the chest condition remains un- 
changed, resolution taking place very slowly. These always 
cause much anxiety to the physician because of the possibility 



204 THE DISEASES OF CHILDREN 

of the pulmonary condition becoming tubercular. The child 
has a progressive loss in weight and appetite, there is pallor, rest- 
\essness and diarrhea, etc. 

Bronchopneumonia may eventuate in an abscess of the lung, 
gangrene, pleurisy with effusion, empyema, any one of which 
complicate the condition greatly and render the prognosis most 
unfavorable. 

Emphysema and bronchiectasis may result, making recovery 
difficult. 

Diagnosis. The principal diseases from which a broncho- 
pneumonia must be diagnosed are bronchitis ^ pulmonary tuber- 
culosis and lobar pneumonia. From bronchitis the diagnosis 
is usually made both from the physical signs and the symptoms, 
though at times it may be difficult to reach a positive conclusion 
at first. 

The signs of a bronchitis are usually bilateral and general 
in distribution, while the signs of a bronchopneumonia are 
usually found at the bases posteriorly. The child does not seem 
so ill in bronchitis, though at first the temperature may be 
higher. The course of the disease is shorter in bronchitis. 

In lobar pneumonia the onset is much more sudden, but fre- 
quently the only diagnostic sign will be the uncomplicated bron- 
chial breathing at one place only, as an apex or base, which in 
lobar pneumonia is so frequently the chief sign. Patches of 
high-pitched breathing with rales here and there is very sug- 
gestive of bronchopneumonia. The temperature in lobar pneu- 
monia runs higher persistently and does not fluctuate so much 
as in bronchopneumonia. There is more apt to be constipation 
in lobar pneumonia, and it is more frequently a primary disease 
than secondary. 

Pulmonary tuberculosis and bronchopneumonia may at first 
be difficult of differentiation, and as a tubercular infection may 
be engrafted on an unresolved bronchopneumonia, it is difficult 
to tell where one begins and the other ends. There is more 
often a history of prolonged ill health in tuberculosis than in 



FOREIGN BODIES IN THE BRONCHIAL TUBES 205 

bronchopneumonia, and the complication of a meningitis more 
often encountered in tuberculosis during its course. In a pro- 
longed pulmonary tuberculosis there is a persistent and rather 
regular run of elevated temperature. (See the accompanying 
chart. ) 

Every case of unresolved bronchopneumonia, with a mild rise 
of temperature,- should be viewed with suspicion, and the vac- 
cination tuberculin test made to clear up the diagnosis. 

Treatment. Poultices and pneumonia-oil-silk jackets should 
not be used. If the temperature is high it can best be con- 
trolled by hydrotherapy and the application of an ice bag over 
the consolidated area. This is applied for an hour, and off an 
hour. 

Counter irritation over the involved area is very beneficial, 
mustard plasters, 1 part of mustard to 6 or 8 parts of flour 
mixed into a thick paste. They should be reapplied as the skin 
will permit, care being taken that a blister is not raised. They 
can probably be applied as often as every three or four hours. 

The tablet recommended in bronchitis, antimony and ipecac, 
1/100 grain each, is of service. 

Dr. J. A. Coutts recommends the use of belladonna given 
in doses of ^ grain every two or three hours to children to three 
years of age. He recommends the large dose in all cases. 

In the application of the bath for antipyretic purposes, it 
should not be cooled down more than to 100° F., and the child 
should be vigorously rubbed during the bath, which is prolonged 
about five minutes. 

The other treatment is largely symptomatic; if the cough is 
very persistent and annoying at night, codeine sulphate, J or ^ 
grain, is very beneficial; the bowels may need some attention, 
castor oil at the beginning followed by 10 grains of bismuth 
subnitrate every three hours. If baby is fed on modified milk 
it should have all its ingredients cut down, not giving more 
than a, fat 2.5 per cent, sugar 6 per cent, proteid 1 per cent 
mixture. 



206 THE DISEASES OF CHILDREN 

Care should be exercised not to give nauseous doses in this 
condition, too much depends on the stomach to abuse it. 

In unresolved pneumonia it is most imperative that a change 
of climate be had as soon as possible, to the pine regions or the 
seaside of the South. The child should remain out of doors 
constantly and sleep out most of the time. 

Cod liver oil and iron or hypophosphites are valuable agents 
during convalescence. 

LOBAR PNEUMONIA. 

Synonyms. Croupous pneumonia, fibrinous pneumonia, lung 
fever. 

Etiology. An acute primary infectious disease of the lung, 
due to an invasion of the diplococcus pneumoniae or the pneu- 
mococcus of Friedlander. It is much more common in children 
under two years of age than is generally thought. Riviere 
shows in 196 cases during the first 15 years that the greatest 
number occurred at the age of two years. Season is a contrib- 
uting cause, it being more prevalent in the late winter and 
spring. Sudden changes in the weather and exposure are pre- 
disposing causes. 

Pathology. The process in the lung is practically the same 
in children as in adults; four stages; congestion; the stage of 
red hepitization, in which there is filling up of the air cells and 
smaller bronchi with products of inflammation and peribron- 
chial and interstitial involvement; grey hepitization, with soft- 
ening and loosening of the exudate ; and the stage of resolution., 
in which there is a removal by absorption and expectoration of 
the extravasated mucus, pus and detritus accumulated in the 
bronchi and vesicles. 

Symptomatology. The onset is sudden in most cases, the 
child becomes suddenly sick without any distinct prodronata, as 
a rule, unless it be vomiting and rigor. The rigor may not be 
noticed in a young child, save by cold extremities, which may 
be overlooked. With the rise in temperature there may be a 



FOREIGN BODIES IN THE BRONCHIAL TUBES 



207 



distinct convulsion, especially in those children who are highly 
nervous, and who usually give a history of convulsive seizures 
with each illness, in which there is a rise in temperature. Con- 
vulsions are more apt to occur in young children with pneu- 
monia than in older ones. 

The temperature rises quickly, being, as a rule, higher than 
in bronchopneumonia, frequently reaching 103° or 104° F. 



DATE 


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FIG. 36. LOBAR pneumonia; crisis seventh day. 



There is an excursion of from 1° to 4° F. between the morning 
and evening records. The respiration is accelerated from the be- 
ginning, frequently being seen as high as 80 or 90 to the minute, 
in fact, this symptom may be the first noticed. With it is the 
characteristic expiratory grunt, and a dilatation of the alse nasi. 
The pulse is accelerated and the ratio in this form of pneumonia 
between pulse and respiration is greatly disturbed; it may be 
as small as 1^ to 1, though 3 to 1 is more frequent, 150 to 50 
being a frequent record. The cheeks are flushed and often the 



208 THE DISEASES OF CHILDREN 

greatest color is noted on the cheek on the same side as the 
affected lung. 

There is usually considerable prostration, the child taking 
but little interest in his surroundings. The urine is scant and 
high colored. Cough is by no means a constant symptom, 
though it is very often present. There is usually no expectora- 
tion even in older children, the mucus dislodged being swal- 
lowed; when expectorated it is thick, viscid and blood-stained. 
If there is an involvement of the pleura over the affected area 
the cough is suppressed as it is very painful, and the breathing 
is chiefly diaphragmatic, and in these cases the expiratory grunt 
is more often noticed. With a pleurisy there is often a fixation 
of the neck and upper extremities, as moving them causes more 
pain. 

Constipation is the rule in lobar pneumonia, and the opposite 
usually in bronchopneumonia. 

One of the best signs as to the amount of compensation which 
exists is the color of the shin, lips and lid conjunctivae. If they 
remain red, in spite of the rapid breathing and evident dyspnea, 
nature is taking care of things. The shin is usually hot and 
dry with no perspiration until after the crisis. 

Termination. The termination of the disease is usually 
sudden, by crisis, in from four to seven days. The temperature 
may fall from 103° or 104° F. to normal or subnormal. The 
temperature may show a slight rise after this drop, which is 
usually designated as the postcrisal rise. Some obscure and 
central cases of pneumonia may be of very short duration, the 
crisis occurring as early as the third day. 

Physical Signs. The pathogTiomonic sign of the first stage 
of pneumonia, the crepitant rale, is not heard much more fre- 
quently in children than in adults, as the case is usually not 
seen early enough. The first sign noted may be a diminished 
respiratory murmur. 

Second Stage. Palpation may give increased vocal fremitus 
if the area of consolidation is large enough and near enough to 



FOREIGN BODIES IN THE BRONCHIAL TUBES 209 

the surface. There is dulness on percussion over the consolida- 
tion and an increased resonance over the uninvolved area. The 
dulness may shade off into the resonant area gradually. 

Auscultation reveals the typical bronchial breathing over the 
affected area. In auscultation over the apices^ posteriorly, the 
normal bronchovesicular breathing of this region must be borne 
in mind. The use of the stethoscope with small bell or chest 
piece is urged as the area of consolidation which is near the 
surface may be small. 'No adventitious sounds may be heard at 
all, but more frequently moist rales are heard on the edges of 
the consolidation, during the first stage, and over all during the 
third stage. 

Care must be taken to differentiate the kind of rale heard and 
its location. Very frequently there is an involvement of the 
pleura over the affected side, in which event the rales are small, 
fine and crackling, and very close under the stethoscope, heard 
most distinctly at the end of inspiration. With involvement of 
the pleura there is pain on coughing. 

Over the unaffected portion of the lung there is an exaggera- 
tion of the normal vesicular murmur. 

In the third and fourth stages the bronchial breathing is 
fainter and there are many rales present, the rale redux, much 
like the rale heard in the first stage. 

Resolution may rarely be delayed, most frequently it is 
prompt and complete within a week after the crisis. Ausculta- 
tion at this time often fails to reveal any difference in breath 
sounds in the two sides. 

The most frequent site of the consolidation has been variously 
stated by different observers. Perhaps the left lower lobe is 
more often affected, next the right upper lobe, then the right 
lower lobe. Apical pneumonia is of frequent occurrence, but 
we believe it is a fallacy to expect meningeal complications more 
frequently in apical pneumonias than when other portions of 
the lung are affected. 

The varieties of pneumonia are usually classified according 



210 THE DISEASES OF CHILDREN 

to the physical signs and the symptoms. Abortive pneumonia 
is that form in which a crisis occurs within a few hours after the 
initial' symptoms, and the lung clears up more slowly ; or there 
may be no positive signs found in the chest. In typhoid pneu- 
monia the case is a prolonged one and the general condition 
is like that of a typhoid fever, but without any symptoms of 
typhoid, save the low state of the patient. In relapsing pneu- 
monia, after a short period of remission of symptoms, there is 
an exacerbation due to an involvement of new areas. This in- 
volvement may be of contiguous lung tissue or an area in the 
opposite lung involved. Pleuropneumonia is a condition where 
the involvement of the pleura is severe, either with or without 
extravasation of fluid. 

The complicatio7is of pneumonia are many and often severe. 
Among these may be mentioned pleurisy with effusion. The 
entire absence of sounds over any area of the lung, especially 
the base, Avith an increase in the dulness is always a suspicious 
occurrence, and effusion into the pleura should be thought of. 
In these cases the resolution is delayed. Exploratory aspiration 
should be performed in obscure cases. 

Meningitis is a very grave complication. As before stated 
meningeal symptoms are not more frequent in apical pneu- 
monia than when the base is affected. The first evidence of 
meningeal involvement may be an intense headache in those 
children old enough to localize pain, with restlessness. There 
is a rise in temperature, pupillary symptoms, perhaps convul- 
sions, etc. 

Diagnosis in some cases of deep-seated pneumonia is at first 
very difficult, as no physical signs are present to aid. It has 
been suggested* that the X-ray illumination of the chest is a 
valuable diagnostic measure. Three forms may be distinguished, 
(1) lobar or fibrinous inflammation, (2) disseminated broncho- 
pneumonic foci, yield no shadow; (3) the so-called central pneu- 
monias, which yield a distinct shadow transillumination. 

*Weill-Shivenet (Arch, de Med des Enfants No. 7 1907). 



FOREIGN BODIES IN THE BRONCHIAL TUBES 211 

The principal condition to be diagnosed from is a hroncho- 
pneumonia, which has been mentioned in the previous pages. 

From the exanthemata, especially scarlatina^ the diagnosis 
is not at all easy, as the early symptoms of both are similar. 

The principal difference is the presence of the sore throat in 
scarlet fever, which is rare in pneumonia. It may take the 
presence of the characteristic rash of scarlatina to differentiate 
the two, in the absence of typical chest signs in pneumonia. 

Prognosis is good. It is graver, the younger the child affected, 
but in uncomplicated cases the mortality should not exceed 20 
per cent under two years of age and 5 per cent in children of 
all ages. 

Treatment. There is no specific for pneumonia, but much 
can be accomplished to alleviate suffering and, I believe, to 
hasten the crisis. 

The patient should be placed in bed at once in as large, and 
airy a room as possible and the windows thro^vn open, no matter 
what the season of the year. Hot-water bags should be kept to 
the hands and feet, and the patient even in winter not too 
heavily covered. It should w^ear an undershirt and night shirt 
or drawers. Oil-silk jackets and cotton- wadded coats are not 
necessary, and, I think, positively harmful. 

An initial dose of calomel should be given as soon as the 
child is seen, preferably in the form of a tablet triturate, finely 
powdered, to a child of one year a grain; 2 grains to an older 
child. Castor oil may also be used to advantage. 

For temperature above 104° F. there should be given a sponge 
bath followed by a brisk rub, but for a lower temperature the 
bath need not be given. With an ice bag to the head for tem- 
perature above 103° F., its rise is frequently prevented. The 
use of ice applied to the affected side, as advocated by Mays 
of Philadelphia, I have found a very useful measure indeed. 

The screw-cap ice bag, partly filled with crushed ice, wrapped 
in a towel and applied to the consolidated area, in my experi- 
ence, has lessened pain, lowered temperature and, I believe. 



212 THE DISEASES OF CHILDREN 

hastened tlie crisis in a number of cases. The bag is applied 
and removed in an hour; on an hour, off an hour, being the 
usual rule. 

It may be necessary in cases of severe hyperpyrexia to use 
the cold pack as described on page 65. Antipyretic drugs are 
mentioned only to be condemned. 

Heart stimulants should not be given as soon as a diagnosis 
of pneumonia has been made, as is so frequently done. Wait 
for the indication and give it for that, and withdraw it as soon 
as possible. Brandy is preferable to whisky, and each article 
should be pure. 

The diet should be liquid, preferably milk, partly skimmed 
and diluted, or buttermilk to older children. Broths may be 
given if milk is not tolerated well, an occurrence most infre- 
quent. It will probably be taken in small quantity, at three- 
hour intervals. Give all the cool water the child will drink. 

In the presence of pain from pleuritic involvement a mild 
sedative, heroin, in ^l. grain dose, to child of one year, or 
codeine sulphate, -J grain dose, may be needed. A mustard 
plaster applied to this area is most beneficial. 

The condition of the pulse and heart's action should be fol- 
lowed closely throughout the attack. If cyanosis is present there 
may be a condition of acute dilatation of the right heart, 
when a prompt dose of nitroglycerine followed by digitalin, 
hypodermically, may be the turning point toward recovery. 

Strychnia can be given with good effect but should not be 
given without a clear indication for its use. 

The bowels should be closely watched and kept freely open, 
prompt medication given when indicated, or resort had to 
enemata. 

In the cyanotic cases oxygen is of great benefit and its use 
should not be postponed too long. 

Watchful nursing should be insisted upon after the fourth 
day when the crisis may be expected, and active stimulation 
used, if needed, at this time. 



FOREIGN BODIES IN THE BRONCHIAL TUBES 213 

After the crisis and resolution has progressed satisfactorily, 
the child should be allowed to assume the upright position 
slowly. 

At this stage the following prescription may advantageously 
be used: 

I^ Ammoniae chloridi gr. iv 

Syr. ipecacuanha 3i 

Elix. simplicis §ss 

Aquae dest. q.s. ad oii 

M. ft. Sol. Sig. One teaspoonful. 

PLEURISY. PLEURITIS. 

This is either primary or secondary, and may be of a simple 
fibrinous variety, or there may be a serous effusion in the 
pleural cavity. 

Etiology. It has been said by some observer, ''Once a pleurisy 
always a pleurisy," implying that the real cause of a pleurisy 
is the tubercle bacillus, and that every case of pleurisy should 
be looked upon with suspicion. 

It is surprising how frequently, in postmortem work, adhe- 
sions are found between the lung and costal pleura, evidencing 
an old pleurisy, perhaps recognized at the time but afterward 
forgotten. 

Pneumonia, the pneumococcus, being the active causative 
factor; traumatism; the exanthemata are frequent causes of 
pleurisy, the streptococcus and staphylococcus being frequently 
present. It is in pleurisy with effusion that the tubercle bacil- 
lus is most often found. These may have found entrance to 
the pleura from the bronchial lymph nodes, the intestinal tract 
or the trachea having been the original port of entry. 

Pathology. The fluid when aspirated usually flows freely, is 
albuminous, clear, and of a greenish tinge. If infected with 
pus-producing organisms the fluid changes in character to pus, 
constituting an empyema. 

Usually but one side is affected, though there may be an 
effusion in each cavity. 



214 THE DISEASES OF CHILDREN 

If the cavity is full of fluid the lung is compressed and dense 
like liver, sinks in water, and is very dark in color. If the col- 
lection of fluids is in the left pleura there may be marked 
displacement of the heart. 

Symptoms. Pleurisy occurs more frequently in children over 
two years of age. In primary cases, acute in onset, there may 
be a chill, or rigor, pain on breathing, especially when lifted 
or turned in bed or on deep inspirations, soon a hacking, inef- 
fectual cough occurs, and there is fever running as high as 
104° F. Respirations are quick and jerky and chiefly dia- 
phragmatic, unless the diaphragmatic pleura is involved. There 
is great restlessness , and constipation is present, and if asso- 
ciated with tympany the breathing is further embarrassed. 

In the form in which there is a gradual outpouring of serum, 
the symptoms are not so acute, the temperature lower, and as the 
fluid separates the two inflamed layers of pleura, the pain is less. 

The location of the pain is an important aid in diagnosis, 
and often misleading. It may be referred to the shoulder or 
to the iliac region, when upon the right side being suggestive 
of appendicitis. 

In this kind of case the child may be up and around, but list- 
less and not inclined to play continuously. 

The tongue is furred and the appetite capricious or lost en- 
tirely. In evident tubercular cases the clubbing of the fingers 
is soon noticed. 

Physical Signs. Inspection, Limited movement of the af- 
fected side is usually apparent in the first stage of both forms. 
Fixation of the chest is present in effusion, with displacement 
of the apex beat of the heart. 

Mensuration with two tapes sewed together at 1 inch will 
show limited expansion of the affected side. 

Percussion. Only with effusion will there be much change 
in percussion note unless there be a thick fibrinous deposit over 
the pleura, when there will be an impaired resonance, if not 
dulness. Over an effusion there is flatness, an entire absence 



FOREIGN BODIES IN THE BRONCHIAL TUBES 215 

of pulmonary resonance. With a large effusion a line of de- 
marcation cannot be distinctly made out as the pressure on the 
lung and collapse of the bronchi causes a loss of resonance over 
the lung. There is exaggerated puhnonary resonance over the 
unaffected side. 

Palpation. In the pleurisy sicca friction fremitus can be 
felt. The displaced apex beat may often be better felt than 
located by inspection. Over the effusion there is absence of vocal 
fremitus, with probably an increased fremitus over the com- 
pressed lung above. 

Auscultation. If done early in both forms the characteristic 
pleuritic friction sounds are heard, varying from a distinct 
crackle, a sound like pulling two pieces of buttered bread apart 
when held close to the ear, or the sound of creaking leather. 
As soon as effusion takes place these sounds disappear as do all 
breath sounds. There is nothing so eloquent as silence over 
an area of the chest where normal sounds should be heard. A 
high-pitched breathing, due to compressed lung, may be heard 
through a comparatively small layer of fluid. Exaggerated 
high-pitched breathing is heard over the compressed lung, above 
the level of the fluid and over the unaffected lung, due to the 
compensatory work done by it. 

Vocal resonance is absent over the effusion but increased over 
the compressed lung. 

Diagnosis. This is usually easy, especially if the effusion is 
in fairly large quantity. In dry pleurisy there may be some 
doubt as to the exact location of rales heard, whether in the 
finer bronchial tubes or in the pleura, but in connection with 
the other signs the dift'erentiation can usually be made. 

Prognosis. The usual duration of an acute attack of dry 
pleurisy is from 4 to 10 days, and they rarely terminate fatally, 
though the side may remain indefinitely crippled from adhe- 
sions. If there is enough effusion to cause a marked displace- 
ment of the heart, a fatal termination may result. The associa- 
tion of tuberculosis with a pleurisy with effusion should be 
borne in mind and a guarded prognosis given. 



216 THE DISEASES OF CHILDREN 

Treatment. The patient should be put to bed at once and 
an initial dose of calomel given. If the pain is excessive it 
can be controlled by an opiate, Dover's Powder, paregoric, 
heroin or morphine. Much relief can be had also from counter 
irritation by a mustard plaster applied over the site of the 
pain, care being taken not to raise a blister. 

Relief can also be had in some cases by applying an adhesive 
plaster strip as would be applied for a fractured rib, limiting 
the motion of that side. The strip should be applied at the end 
of a deep expiration. 

Aspiration in cases of effusion should be done only in those 
cases in which there is no evidence of an attempt at absorption 
at the end of two weeks, or where there is great dyspnea or 
marked displacement of the heart from left-side effusion. Only 
a relatively small amount of fluid should be withdrawn, the 
point of selection being the interspace about the middle of the 
area of greatest dulness, the patient in the upright position if 
possible, leaning forward to hold tissues tense. 

The skin should be most carefully prepared by soap and water 
and alcohol and the needle boiled. The aspirator should be 
tried with the needle in sterile water to be sure that the current 
of suction is not reversed. The upper border of the rib should 
be hugged by the needle to avoid the vessels. !N'o local anes- 
thetic is needed, as a rule, though ethyl chloride may be used. 

The iodides are indicated, syr. iodide of iron being most 
efficient, in half teaspoonful doses to child of two years. 

Nourishing food, plenty of fresh air and a change of climate 
is most beneficial. 

EMPYEMA. 

A collection of pus within the pleural cavity. 

Etiology. This may be the result of an infection of an 
extravasated fluid in a pleurisy, or an original or primary 
infection of the pleura due to the pneumococcus, streptococcus 
or staphylococcus. It is very rarely an original infection, being 



FOREIGN BODIES IN THE BRONCHIAL TUBES 217 

secondary to pneumonia in fully 90 per cent of cases. It may 
also complicate diphtheria and the exanthemata, in fact, any 
infective process may cause it, tonsillitis, pyema, osteomyelitis, 
etc. It may be of traumatic origin. In children the tubercle 
bacillus is more often responsible for pleurisy with effusion 
than empyema. It more often affects children between six 
months and three years of age, although no age is exempt. 

Pathology. With a large collection of pus as in pleurisy with 
effusion there is a displacement of the heart. There are numer- 
ous adhesions between the two layers of pleura. The pus is 
thick, a very dark yellow, and many lumps may be present. 
This fact must be borne in mind in aspiration, for either diag- 
nostic or curative purposes. 

There is an associated unresolved pneumonia, the consolida- 
tion being more of the lobar than the broncho type. If there 
is much fluid there may be a compression of the lung without 
consolidation. 

An infection of other serous cavities may complicate an 
empyema, a pericarditis, endocarditis, peritonitis or synovitis. 
Bronchopneumonia may arise as a complication, especially if 
there is a rupture of the fluid into the lung. 

Symptoms. In primary cases the onset is sudden, a chill or 
rigor, usually, with pain and dyspnea, much the same as in a 
pneumonia; a rise of temperature to 103° or 104° F. The fever 
is usually irregular, a morning remission and high in the even- 
ing, followed by a sweat. It must be borne in mind, however, 
that there may be a large accumulation of pus in the cavity and 
a comparatively small rise in temperature. In secondary cases 
there may have been an apparent improvement in the pneu- 
monia with a gradual rise in the temperature, and increase in 
all the symptoms, the cause of which may not be clear without 
a careful physical examination. The cough returns and be- 
comes quite annoying, with no expectoration, there is a pro- 
gressive loss in weight ; some pain in the affected side, especially 
when taking a long breath ; loss of sleep ; no appetite ; rest- 



218 THE DISEASES OF CHILDREN 

lessness ; constipation ; anemia and a tendency to clubbing of the 
fingers. There may be a decided interference with respiration, 
so the child has to be held or propped partly up in bed. The 
dyspnea may not be noticed markedly unless the patient is 
moved, or turns suddenly in bed. This is specially the case 
if there is enough effusion to ^ cause a displacement of the heart 
and large vessels. 

Physical Signs. There are no essential differences in the 
signs found in empyema and in pleurisy v\^ith effusion, save 
when an empyema complicates a pneumonia, owing to the thick- 
ness of the fluid and its better conducting power, bronchial 
breathing may be heard through it. This bronchial breathing 
is usually more distant and faint than that heard above the 
level of the pus over the compressed lung. The effusion is 
usually at the base, but may be localized at several points owing 
to the possibility of adhesions forming and the fluid becoming 
pocketed. Collections of pus at the apex may occur, but very 
rarely. 

Diagnosis. The diagnosis is principally from a lobar or 
broncho pneumonia, and pleurisy with effusion. The physical 
signs are to be relied upon principally for a diagnosis. In 
lobar pneumonia the crepitant rale heard early may be mis- 
taken for a pleuritic friction sound, but this is rapidly followed 
by bronchial breathing and dulness, whereby the bronchial 
breathing, if heard at all over the extravasation of fluid, is heard 
late. There is no displacement of the heart in pneumonia, the 
percussion note is flat in empyema. A leucocyte count may 
assist in the diagnosis of an empyema. The polynuclear per- 
centage is high in empyema. From pneumonia, as well as 
pleurisy with effusion, it may remain for an exploratory punc- 
ture to clear up the diagnosis. This must be done under the 
strictest aseptic precautions, careful sterilization of the needle 
and preparation of the field and hands. A needle of sufficient 
size should be chosen to allow thick pus to flow through. It 
may be necessary to examine a drop of the fluid microscopically 



FOREIGN BODIES IN THE BRONCHIAL TUBES 219 

to definitely determine its nature, as serous pleural effusion is 
often very turbid, resembling pus. 

Prognosis. This can be said to depend to a great extent upon 
the promptness of diagnosis and the method of treatment em- 
ployed. Age, previous illnesses and cause also influence the 
outcome as v^ell as the presence and nature of complications. 
In cases in v^hich there is a mixed infection the prognosis is 
not so good. Purely pneumococcus infections are more favorable. 

Treatment. The treatment of empyema is surgical, and three 
methods are in vogue, aspiration, simple incision and rih resec- 
tion. Aspiration should not be resorted to except as a diagnostic 
measure. A large quantity of pus may be withdrawn but its 
tendency is to quickly reform. 

As the indication is quick removal of the pus as soon as 
recognized, the best method of removal is an incision of the inter- 
costal space, with tube drainage afterward until the pus ceases 
to flow. The point to be selected for the incision should be 
carefully made, the object being to have the opening at as 
dependent a point as possible, bearing in mind the probable 
sacculation of the fluid. 

Usually the seventh or eighth interspace is chosen about the 
posterior axillary line, and the incision made 2 or 2-J inches 
long, close to the upper border of the rib, this being advantageous 
in avoiding vessels and nerves, and is more convenient in case 
a rib resection is later necessary. 

With strict aseptic precautions the incision is made under a 
local anesthetic, cocaine or ethylchloride, down to the pleura. 
A general anesthetic is dangerous. The pleura is nicked and 
the opening enlarged with an artery forceps, and a considerable 
quantity of pus allowed to escape. Drainage tubes, previously 
prepared, fenestrated and armed with large safety pin? in the 
outer end, are pushed in the cavity, and the remainder of the 
pus allowed to flow out into the dressings, which are imme- 
diately applied. Gauze, absorbent cotton, waste or oakum, make 
good dressings in the after treatment. The first may be used 



220 THE DISEASES OF CHILDREN 

wet to facilitate absorption. Should the pus be very thick and 
not flow freely a subperiosteal rib resection should be done. The 
incision is slightly enlarged, the rib exposed, the periosteum 
elevated, and a section of the rib 2 or 3 inches in length removed 
with bone forceps. A tube is then placed in this opening and 
drainage is much more free. 

The after treatment of the operative cases consists in daily 
or more frequent dressing, removal of the tube each day and 
cutting off from half an inch to an inch and replacing it, 
until by the end of the week it can be removed entirely. 

Irrigation of the pleural cavity should be discouraged always. 

Vaseline or oxide of zinc ointment can be used to advantage 
on the skin around the opening to prevent excoriation. The 
tube had best be pinned to an adhesive plaster strip and this 
applied to the skin to prevent its slipping into the cavity. 

On the removal of the tube for good a small strip of gauze 
should be carried into the opening for a few days to prevent its 
closing too quickly. * 

Deformity of the chest, due to failure of the compressed lung 
to properly contract after evacuation of the pus is sometimes 
seen. 

GANGEEKE OF THE LUNG. 

This is a rare condition in children, and may only be recog- 
nized at the autopsy table. 

Etiology. Some process has been present in the lung pre- 
viously, favoring bacterial invasion, as a pneumonia or empy- 
ema, or as a complication of noma, the exanthemata, tonsillitis 
or middle-ear trouble. An embolus of septic origin may be a 
cause. 

Pathology. There may be one or a number of foci of 
gangrene; the areas are dark in color and the fluid present is 
gTeenish in color and very foul smelling. There is an area 
of consolidation usually around these gangrenous spots. If 
near the surface a pleurisy generally is found, and they may 
ulcerate through into the cavity. 



FOREIGN BODIES IN THE BRONCHIAL TUBES 221 

Symptoms. These may be obscure, and unless a bronchus be 
invaded by rupture of a gangrenous area and some of the fluid 
expectorated the condition may not be suspected. This fluid 
is dark, thick, contains pus, blood, mucus and lung tissue, and 
is foul smelling. 

If complicating or following a pneumonia, there is an exacer- 
bation of the . symptoms, prostration, usually a foul breath, 
increase in fever, quite rapid loss of flesh and strength, and 
sweats. 

Physical Signs. Unless a gangrenous area has broken down, 
forming a cavity, the signs may not vary from those found in a 
pneumonia. In this even cracked-pot resonance; amphoric 
resonance, and probably gurgles may be found. 

Treatment. When a diagnosis has been made and the site of 
the trouble located positively, a pneumonotomy is indicated fol- 
lowing a rib resection. Tonic treatment and stimulation should 
be begun early. 



CHAPTER XII. 

Diseases of the Digestive "System, 
diseases of the lips. 

herpes. 
Synonym. Fever blister. 

This is a common affection of childhood chiefly complicating 
digestive disorders, pnenmonia and the infections diseases. 
There are small vesicles which appear on the mncons membrane 
of the lip or npon the skin of either or both lips ; they may 
be discrete or coalesce, forming one large vesicle. The vesicle 
is located on a reddened area; it shortly dries and becomes en- 
crnsted. There is a burning sensation at the site of the vesicle, 
before it makes its appearance. 

Treatment. An initial dose of calomel or castor oil will often 
limit the size of these vesicles. Locally, dry calomel applied 
to the vesicles is of service in drying them. Prevent the child 
from picking and infecting the vesicle. 

ULCERATIONS AT ANGLE OF MOUTH. 

Synonym. Perleche. 

Definition. This is a form of cracking of the mucous mem- 
brane or u.lceration at the angle of the mouth, first described 
by Lemaistre. 

Etiology. It begins as a small fissure or crack at the corner 
of the mouth, which becomes infected by frequent rubbing and 
touching by the tongue, and remains at this point entirely. It 
is more frequently seen in marasmic and anemic children. 

Symptoms. The erosions are generally linear in shape, con- 
fined to both corners of the mouth, are slightly elevated with a 

222 



DISEASES OF THE DIGESTIVE SYSTEM 



223 



red and indurated base. It is painful if the child opens its 
mouth wide, as when yawning. They may be mistaken for the 
rhagades of syphilis, but no mucous patches are found in the 
mouth in perleche. 

Treatment. The course of perleche is usually for two or 
three weeks. It can be helped by applying a 5 or 10 per cent 




FIG. 37. HERPES LABIALIS. 



solution of nitrate of silver direct to the surface, followed by 
a drying powder, as zinc oxide or bismuth. The application of 
an ointment to these areas prevents the encrustation over them ; 
bismuth, gr. x, to vaseline, 3i, 3 per cent resorcin ointment, 
benzoinated oxide of zinc, yellow or red oxide of mercury, are 
efficient. The use of the ointment following the silver, in win- 
ter, is specially desirable. 



224 the diseases of children 

Diseases of the TojN'gue. 
epithelial desquamation. 

This condition is also known as the geographical tongue. 
There is an abrasion or exfoliation of the epithelium in irreg- 
ular areas over the surface of the tongue with normal or slightly- 
coated surface between. The areas are slightly elevated, and 
when freely desquamated leave a red base. It occurs frequently 
in bottle-fed infants and causes no discomfort; as a rule re- 
quires no treatment other than cleansing washes of boracic acid 
solution. 

Diseases of the Mouth. 

bednar's aphtha. 

Pathology. This is a symmetrical ulceration, one on each 
side of the median line of the soft palate at its juncture with 
the hard palate. It is most frequently seen in the new-born 
or infant under six months of age. 

Etiology. It is caused by the finger of the nurse too vigor- 
ously cleansing the mouth, an abrasion of the mucous membrane 
occurring readily at the attachment of the soft to the hard 
palate, bacterial invasion taking place at this site. 

Symptoms. The child probably refuses to nurse or it may 
nurse for a few moments, stop and fret on account of the pain. 
Inspection of the mouth with tongue held down reveals two 
symmetrical, round ulcers at the point indicated above. They 
may have a greyish surface, slightly elevated, with reddened 
area at its base. 

ISTitrate of silver solution, 5 per cent, applied directly to the 
surfaces, once daily, and the mouth in front of these ulcers 
washed after each nursing, usually will cure them in a few 
days. 

stomatitis. 

This may be of the following varieties : Catarrhal, herpetic, 
or aphthous and ulcerative. 



DISEASES OF THE DIGESTIVE SYSTEM 225 

The catarrhal variety is caused by irritants ; trauma ; ex- 
cessively-hot liquids or food, or secondary to exanthemata. 

There is an intense reddening of the mucous membrane, and 
desquamation of the epithelium and a salivation. 

Symptoms. There is a sensation of heat and pain in the 
mouth ; profuse salivation ; child will not nurse ; is fretful and 
cries a great deal, may be vomiting ; enlargement of glands sub- 
maxillary and at angle of jaw; sleeps with mouth open. The 
duration in robust children is usually only a few days. 

Treatment. But little is required. Antiseptic mouth washes ; 
crushed ice. If no food is taken for some days gavage is of 
service. 

HERPETIC STOMATITIS. 

Etiology. Teething, irritating substances in the mouth, and 
as a complication of gastrointestinal disorders. 

Pathology. Small vesicles appear on the mucous membrane 
of the lips and cheek; these may coalesce, forming large ones. 
They are superficial as a rule and associated with more or less 
general hyperemia, especially of the~ area of mucous membrane 
directly about the bases. 

Symptoms. The presence of the characteristic vesicles in the 
mouth; salivation, difficulty in nursing; enlarged glands. The 
chief difference is in the appearance of the vesicles. 

Treatment. Care should be taken in using an antiseptic or 
cleansing wash, not to rub the vesicles so as to leave an abraded 
surface below. Chlorate of potash, 2 or 3 grains, well diluted, 
to a child of two years is of great benefit. If the areas coalesce 
and leave a raw base, nitrate of silver is of service, in a 10 per 
cent solution. 

ULCERATIVE STOMATITIS. 

Pathology. An ulceration which usually begins at the base 
of a tooth and spreads over the gum to the mucous membrane of 
the lips and cheeks. The ulcers usually have a whitish, de- 



226 THE DISEASES OF CHILDREN 

pressed surface with red edges. There may be deep ulceration 
at roots of teeth causing them to loosen and fall out. 

Etiolog^y. It is of bacterial origin, may follow the exan- 
themata, and complicate carious teeth. It is seen in wasting 
diseases also. 

Symptoms. Pain when chewing is attempted, excessive flow 
of saliva, fetid breath, tongue thickly coated, ulcers bleed freely 
if touched, sordes on teeth, child is fretful and cries a great 
deal. The gangrenous form may supervene. 

Treatment. Weak peroxide of hydrogen of solution 25 per 
cent dilution, followed by an antiseptic wash ; saturated boracic 
acid solution, full strength, Dobell's solution, or solution made 
from Seller's tablets. The internal administration of potassium 
chlorate is almost a specific, and should be given in 2 or 3 grain 
doses to child of two years. The local application of nitrate of 
silver solution, 10 per cent, to the base of the ulcers is of service. 

GANGRENOUS STOMATITIS. 

Synonyms. Noma; camcarem oris; gangrene of cheek; 
W angenhrand. 

This is a sloughing or gangrenous process involving the 
mucous membrane and tissues of the cheek, as a rule, though 
it may spread to the gums and lips. Sufficient tissue may be 
involved to have a perforation of the cheek. Both sides of the 
mouth may be simultaneously affected. It usually occurs be- 
tween two and six years of age. 

Etiology. !N^o specific organism has been satisfactorily iso- 
lated in these cases, though two Russian observers claim to 
have isolated a small bacillus and produced the same conditions 
in guinea-pigs. The diphtheria bacillus, strepto- and staphylo- 
cocci, have been found, ^oma occurs after the exanthemata, 
and diphtheria, after any wasting or prolonged disease in which 
resistance is low, and may start from a severe ulcerative 
stomatitis. 



DISEASES OF THE DIGESTIVE SYSTEM 227 

Pathology. The starting point is usually on the gum near the 
teeth, and these quickly spread to the mucous membrane of the 
cheek. The area involved is more or less symmetrically round, 
and at first can be felt as a small, hardened mass which soon 
breaks down, leaving a dark, angry-looking area, bathed in pus, 
and from which a foul odor emanates. In some favorable 
cases a mass of tissue separates and falls out, leaving a hole 
covered with granulation tissue. 

Symptoms. At first there are few general symptoms, but 
soon there is fever to 103° or 104° F. ; great restlessness; pain; 
inability to chew or swallow; fetid breath, which is noticeable 
as soon as the room is entered; the cheek is much swollen and 
indurated, the edema spreading to the upper and lower eye- 
lids ; the skin of the cheek assumes a dusky, dull red color. 

In a few hours the slough has extended, and in one to Rye 
days unless the process is arrested, the cheek will probably be 
perforated. At the same time the gangrene may extend to the 
lower or upper jaw, involving the bone and causing the teeth 
to loosen and drop out. There is a septic diarrhea, and at this 
stage great prostration with rapid and feeble pulse. 

Prognosis. The prognosis is grave, fully 75 per cent suc- 
cumb in spite of treatment. The duration is from one to three 
weeks, and death ensues from either toxemia or broncho- 
pneumonia. 

Treatment. Attention should always be given to stomiatitis 
of any form, especially the ulcerative variety, to prevent the 
engrafting of a cancarem oris upon it. As soon as the diagnosis 
has been made, under a general anesthesia, the area involved 
should be thoroughly cleansed and cauterized with the fine tip 
of a Paquelin cautery, and the cauterization should extend be- 
yond the diseased area. I have had one case recover treated in 
this manner without perforation of the cheek, but ulceration 
extending very close to the skin. 

In this case an examination of scrapings from the ulcer re- 
vealed no organisms except the pus-producing ones, 



228 THE DISEASES OF CHILDREN 

The diseased area should be touched each day with a 20 per 
cent nitrate of silver solution, and a cleansing antiseptic mouth- 
wash used. 

It is wise to have a culture made from scrapings from the 
mass, and the diphtheria bacillus looked for. If isolated, the 
child should be given a dose of diphtheria antitoxin at once. 

Active supportive and stimulating treatment must be used, 
such concentrated nourishment as beef juice and broth, pep- 
tonized milk, egg-nogg, etc. 

THRUSH. 

Synonyms. Sprue, muguet, so or. 

This is an affection of the mucous membrane due to the 
growth upon it of a specific organism, the saccharomyces 
albicans. 

Etiology. The saccharomyces albicans and not the oidium 
albicans is the cause of the condition. Examination of the 
deposit shows the white threads or mycelium and the small, 
oval bodies, the spores. It is usually limited to the mucous 
membrane of the mouth, but may spread to the larynx, esoph- 
agus and stomach. The organism is carried to the mouth, either 
upon the ordinary nursing paraphernalia or the rubber nipple 
^persuader" or ^^comforter") toys, sugar-teats, etc. 

Symptoms. Upon the tongue, gums and mucous membrane 
of the lips, later of the cheeks, there is a white deposit varying 
in size from a pin point to an area the size of the little finger 
nail, the larger masses resembling a mass of curds. Patches 
may be found here and there, or may be very numerous. There 
is apt to be a coincident gastrointestinal involvement, and the 
whole area of buccal mucous membrane is hot, red and dry. 
The child refuses to nurse, or if older its bottle or ordinary 
food is pushed aside. 

This condition is due, as a rule, to neglect or to over-zealous 
cleansing of the mouth, resulting in an abrasion in which be- 
comes engrafted the infective organism. 



DISEASES OF THE DIGESTIVE SYSTEM 229 

Treatment. The best treatment is prophylaxis. It can be 
prevented by careful attention to details of cleanliness, of both 
baby and nursing paraphernalia and breasts and nipples of 
mother, i^ursing infants are less apt to develop sprue than 
older ones. The occurrence of sprue is usually an indication 
that the nurse or person in charge is careless about the toilet 
of the mouth before and after nursing, and of the bottles and 
nipples. 

Saturated solution of boracic acid is an efficient remedy and 
preventive as well. The finger wrapped in absorbent cotton 
is wet with the boracic acid solution and the deposit gently 
removed. 

This must be done very gently at all times, as the mucous 
membrane is very easily abraded. The cotton is best changed 
as one part is cleansed. If an aphthous or ulcerated spot is 
found it should be touched with a nitrate of silver solution. 
A cure is generally had at the end of a week or so. 

GOTs^OREHEAL INFECTION OF THE MOUTH. 

This is generally associated with an acute infection in the 
mother of a similar nature, urethral, vulvovaginal, conjunctival, 
and is due to the specific organism, the gonococcus of ITeisser 
being transferred to the child's mouth. There must first be a 
trauma, not necessarily macroscopic in size. It occurs usually 
before the child is two weeks old. Fortunately this is a rare 
infection, but few cases having been reported. 

Symptoms. These may be very few, and it is entirely pos- 
sible for the condition to go entirely unrecognized. It may 
become engrafted upon a Bednar's aphthae or an abrasion of 
the mucous membrane due to cleansing the mouth. The swelling 
and appearance of the mucous membrane is like that seen in 
catarrhal stomatitis, and to be recog-nized scrapings from the 
mucous membrane must be examined microscopically. There 
is but little discharge. It usually runs a short course. 

Treatment, Cleanliness, frequent washing with boracic acid 



230 THE DISEASES OF CHILDREN 

solution, and twice daily swabbing out the entire buccal mucous 
membrane, especially under the tongue and lips and gums with 
a 2 per cent nitrate of silver solution, or the same strength solu- 
tion of protargol. 

Care must be taken to protect the eyes and thumb-sucking 
must be prevented. 

SYPHILITIC STOMATITIS. 

When snuffles in a new-born child is seen the mouth should 
be carefully searched for possible mucous patches. 

Any case in which ulcers are found upon the buccal mucous 
membrane should be looked upon with suspicion. 

Typical mucous patches are not as deep as the ulcers of non- 
specific ulcerative stomatitis, are usually upon the lips or mu- 
cous membrane of cheeks, and more rarely on the gums. They 
have a dull, white base and may be bathed in a thin pus secre- 
tion. They may be associated with fissures at the corners of 
the mouth. 

Local application of a mild antiseptic wash, with vigorous 
antisyphilitic treatment is indicated. 

EANULA. 

This is a cystic formation under the tongue, on either side of 
the frenum, and is due to an occlusion of one of the salivary 
ducts or a duct from one of the mucous glands, a Bland-l^uhn 
or Rivinian Gland. There may be a lodgement of a small cal- 
culus in the duct, closing it. 

Symptoms. When the tongue is raised a small, soft, fluctu- 
ating tumor is found under the tongue. The calculus may be 
felt if present. These may be of such size as to interfere with 
nursing and with swallowing, even with the closure of the 
mouth. 

Treatment. Incision of the cysts, the child being held on 
the nurse's lap, head between physician's knees, who sits facing 



DISEASES OF THE DIGESTIVE SYSTEM 231 

the nurse. The tongue can be held out of the way by means 
of the handle of a grooved director. 

Saliva or a viscid mucus may escape on incision of the cyst. 

TON-QUE-TIE. 

Every new-born baby's mouth should be examined, and the 
frenum of the tongue especially inspected. If a baby cannot 
protrude its tongue between or at least to its lips, the frenum 
is too short, the tip folding on itself, making it difficult to form 
a vacuum and the nursing is interfered with. This is seen com- 
paratively infrequently, and when clipped causes great relief. 
' Treatment. The child is held as described in the treatment 
of ranula, and the tongue held by the handle end of a grooved 
director, the frenum projecting through the slit in this. It is 
then cut with a pair of blunt-pointed scissors which have been 
previously set so as to make the cut of prescribed depth, and if 
this does not liberate the tongue sufficiently it is torn by the 
finger as needed. The bleeding is usually very slight. 



This condition, described by Dr. Guiseppe,* occurs more 
frequently in Southern Italy, and is mentioned because of its 
likeness to more benign conditions occurring in this country 
just described. It was first exhaustively studied by Riga in 
1880. It does not occur epidemically. The etiology is very 
obscure. 

Symptoms. It usually occurs in vigorous and previously 
healthy children during the first six months of life. An ulcer 
or granuloma forms at the side of the frenum of the tongue, 
dirty gray in color. The child falls suddenly ill with the 
appearance of the ulcer, suffers with severe collapse and soon 
dies. 

The treatment is of no avail. 

* Gazz. DegU ospedaU-delle clin., No. 153, 1907. 



232 THE DISEASES OF CHILDREN 

ALVEOLAE ABSCESS. 

This is an infection of the gum or the alveolar process, orig- 
inating usually in a tooth. The conditions may result in an 
abscess which will discharge within the mouth, but it is not 
at all uncommon for them to open externally, through the cheek, 
at the angle of the jaw or below the chin. 

Symptoms. Usually there is a period during which the child 
complains of toothache, and an examination of the mouth may 
reveal a cavity which is filled with food particles. After the 
subsidence of the pain the swelling begins and this is apt to be 
painless, or nearly so. 

The swelling is firm and tense with some redness of the skin. 
The mucous membrane of the affected side is edematous. Pus 
usually is found and frequently can be pressed out from the 
gum along the tooth. 

Treatment. Much more care should be given the teeth of 
children than is usually the case. Too frequently their cleans- 
ing is left entirely to the child and not supervised, food collects 
and an infected gum results. Children should be taken to a 
dentist at least twice a year, the teeth carefully inspected, and 
attention given those which show sign of softening or breaking 
down. 

Wlien an abscess forms it should not be allowed to rupture 
outside but opened on the inside of the mouth. It sliould then 
be treated as any other abscess and free drainage maintained. 

FISTULA OF NECK ( BRANCHIAL FISTULA). 

A branchial fistula is a congenital failure of the second and 
third branchial clefts to close. An opening persists in the neck 
ending at the inner side of the sternocleido mastoid muscle, 
near the sternoclavicular joint. One or both sides may be 
affected ; if one, it is usually the left. 

The tract may end in a blind pouch but usually leads in a 
more or less straight course to the esophagus or pharynx. If 



DISEASES OF THE DIGESTIVE SYSTEM 233 

the external opening closes a cyst usually forms rapidly, it being- 
called a branchial cyst. The contents of these cysts vary, in 
different cases. They may contain mucus, serum, serum and 
blood and epithelium. 

Treatment. The treatment of both conditions is entirely 
surgical. 

ACUTE ESOPHAGITIS. 

An acute inflammation of the esophagus which usually is 
caused by the passage of a foreign body, the swallowing of a 
caustic as a lye solution or acid, or ammonia. It may follow 
an acute inflammation of the mouth and pharynx, as in diph- 
theria or thrush. 

Symptoms. The severity of the symptoms depends entirely 
upon the strength of the irritating substance swallowed and 
the severity of the inflammation, if it is an extension from 
above. In all cases there is great and continuous pain, dys- 
phagia, retching, perhaps vomiting, which greatly increases the 
pain. 

The vomitus may contain pus and usually some blood. There 
is a greatly increased flow of saliva. Restlessness is a marked 
symptom. 

There is a swelling of the mucous membrane of the mouth 
and pharynx, and if this is very great there may be considerable 
dyspnea following the swallowing of the irritant. 

The sequel in these cases which is most to be feared is a 
stricture of the esophagus. A spasmodic stricture may appear 
as early as the second day, the cicatricial stricture at a later 
date, after a week or two, or it may be delayed several weeks. 

Treatment. The treatment of the cases after the injury is 
medical. Morphia in appropriate dosage to control the mus- 
cular spasm and pain ; no food or water by the mouth ; sustain 
the child by nutrient enemata; cold applications externally to 
neck. As soon as it is evident that an esophageal stricture is 
present, evidenced by a muscular spasm on swallowing and 



234 THE DISEASES OP CHILDREN 

regurgitation at once, or entire inability to swallow solid food 
and difficulty in swallowing liquids ; under a general anesthetic 
chloroform or somnoform, the' esophagus should be carefully 
explored by esophageal bougies, olive-tipped, to locate the num- 
ber and location of the strictures. Makenzie has stated the dis- 
tance in a child of about two years from the gums to the cardiac 
orifice to be about 7 inches. The location of the strictures accom- 
plished, their size should be ascertained by passage of pro- 
gressively larger bougies, and this repeated at intervals of three 
or four days. 

With an impassable stricture the case becomes surgical and 
may eventuate in a gastrotomy. 

STENOSIS OF THE PYLORUS. 

Our knowledge of pyloric stenosis is directly the result of 
postmortem investigations. A pyloric tumor* is almost uni- 
formly found about the size of the end of the thumb. It is free 
from adhesions, oval in shape, firm, hard and smooth. It is 
located at the pylorus and when present makes easy the location 
of the pylorus, which is difficult ordinarily. 

Microscopically there is found a hyperplasia of the circular 
muscular fibers, and a very great hypertrophy of the folds of 
the mucous membrane, which lie longitudinally. Secondary 
changes occur in the stomach, namely a dilatation and thinning 
of its walls. 

Symptoms. The child is apparently normal when born. 'No 
symptoms are present, as a rule, until the third or fourth day, 
when the first noticed will probably be vomiting. There is a 
disinclination to nurse. The vomiting may be delayed as late 
as the end of the second week. The vomiting is characteristic, 
being expulsive, violent and persistent. One or two nursings 
may be retained, and then the total swallowed is violently 
ejected. The child is nearly always restless and uncomfortable 

* Scudder: Boston Medical and Surgical Journal, August 6> 1908. 



DISEASES OF THE DIGESTIVE SYSTEM 235 

after nursing and apparently relieved only by vomiting. 'No 
nausea is present. 

Examination of the vomitus may show free hydrochloric acid, 
but it is not increased in amount; usually there is no bile 
present, no blood or lactic acid. 

There is obstinate constipation, and what is passed for a 
number of days continues to be like meconium in appearance. 

The child instead of gaining its second week continues to 
lose in weight. The temperature is below normal and the pulse 
fast, out of proportion. 

Examination of the abdomen may reveal a fairly character- 
istic condition ; a distension of the abdomen above the umbilicus, 
and a wave of peristalsis may be seen moving from left to right. 
This is best seen in a good light after a feeding. Below the 
umbilicus the abdomen is collapsed and concave. Palpation 
may reveal a pyloric tumor one-half inch to the right and three- 
fourths of an inch above the umbilicus. 

The tongue is clean and the breath normal. 

Diagnosis is principally from gastric indigestion. In these 
cases the vomiting does not occur as regularly, or if more infre- 
quent the amount vomited is not so large or as expulsive as in 
stenosis. The bowels, after a few days of gastric indigestion, 
are apt to be loose and contain mucus, and the loss in weight 
is not so rapid. There is no tumor present except in stenosis. 

Prognosis. This depends entirely upon the early recognition 
of the condition and the promptness of surgical intervention. 
The mortality following operation is high. Of 135 cases col- 
lected by Scudder" the mortality was 48.8 per cent. He esti- 
mates the mortality of medically-treated cases as between 80 
and 9(^ per cent. 

Treatment. This is essentially surgical. An operation should 
be performed immediately the diagnosis is made. Scudder 
mentions three operations: The Loreta operation, consisting 
in opening the stomach and stretching the pylorus by a pair 

* Scudder: (Canadian Practitioner, August, 1908, p. 95. 



236 THE DISEASES OF CHILDREN 

of forceps introduced through this opening. Second, pyloro- 
plasty and incision from the stomach into the duodenum, across 
the pyloric tumor, and suturing this incision so as to increase 
the lumen to the pylorus. Both these methods he discredits as 
dangerous and unsatisfactory. Posterior gastroenterostomy is 
recommended after the Mayo method. Several times before the 
operation it is advised to give an enema of brandy and salt solu- 
tion. Stomach washing just before the operation. Arms and 
legs confined to body with separate sheets. Median incision to 
left of umbilicus. Layer suture of wall after operation will 
lessen possibility of hernia. 

The after treatment is important, the Fowler position; very 
careful feeding of Avhey or barley water or breast milk diluted, 
10 or 12 hours after the operation, first, a teaspoonful, grad- 
ually increased to a tablespoonful every three hours. Breast 
milk should be substituted as soon as possible. 

Vomiting may recur two or three times a day after the opera- 
tion, but gradually subsides. 

DISEASES OF THE STOMACH AND INTESTINES. 

General Considerations. The digestion of infants and children 
is essentially different from an adult. The new-born infant's 
stomach is a dilated end of the esophagus, without much shape, 
but it quickly assumes, however, the shape of the adult stomach. 
Saliva is secreted in very small quantities until after the erup- 
tion of the deciduous teeth. The stomach of the infant fed upon 
mother's milk should empty itself in two hours, a slightly longer 
period being taken in the stomach preparation of cow's milk 
for digestion and absorption. At rest the stomach contains 
mucus and but little acid, in the presence of milk, hydrochloric 
acid is secreted. Lactic acid is found occasionally, not always. 
Free hydrochloric acid is not found immediately after a nursing, 
but in from one to two hours following. 

The principal duty of the stomach in digestion is the precipi- 
tation of the casein, the proteid in mother's milk coagulating 



DISEASES OF THE DIGESTIVE SYSTEM 237 

in small llocculi. that of cow's milk in larger masses. Tlie rennet 
ferment or labferment is the coagulating agent. From the 
stomach the contents pass into the duodenum where digestion 
proceeds, aided by the pancreatic juices. Here the carbo- 
hydrates, peptones and fats are digested and absorbed, the pan- 
creatic ferments being trypsin, steapsin and ptyalin. The bile 
aids in the emulsifying of the fats. The digestion of fat is a 
problem which is as yet not fully imderstood, but it is a fact 
that fat causes much more trouble than is usually believed. 

The bacteria of the stomach and intestines are not fully inves- 
tigated, especially of the former. The principal bacteria which 
may be found in the stomach are the bacterium lactis cerogenes, 
bacillus coli communis, sarcini ventriculi, the hay bacillus^ 
and other non-pathogenic organisms. 

The Shiga bacillus, belonging to colon typhoid group, has 
been found in the intestinal discharges in certain cases of diar- 
rhea, especially in those in Avhich the discharge of mucus and 
blood is present. Further study may reveal much of the life 
history of this organism, both in and out of the intestinal tract. 
Among the others most frequently found are the bacillus coli 
communis, streptococci, staphylococci, the bacillus lactis cero- 
genes and the bacillus subtilis. 

The number of stools in the 2i hours varies greatly in differ- 
ent babies, the character, consistence and color of the passage 
being an indication of whether a comparatively large number 
is within the range of normal. The nursing infant during the 
first few weeks may have from three to four movements in the 
24 hours, after this period they are less frequent, but at least 
one passage should be had in 24 hours, and under no condition 
should this be varied from. 

The number and character of the bacteria in milk bear a 
certain relation to this phase of the subject. It is well known 
that ordinary market milk contains from 300,000 to several 
million bacteria to the cubic centimeter, and it has been re- 
peatedly shown that such milk fed to infants results directly 



238 THE DISEASES OF CHILDREN 

in serious digestive disturbances and frequently in severe toxic 
and inflammatory conditions of the stomach and intestines. 

The Feces. The feces of the new-bom are thick, black, tarry- 
like and tenacious, called meconium. These characteristic move- 
ments give way to the normal stool of the infant. These are 
yellow, smooth, consistent and mush-like, as soon as the moth- 
er's milk is secreted or when milk is fed artificially, the black 
color being gradually replaced by the yellow toward the third 
or fourth day. The mother's milk varies so in its analysis at 
different times of the day and night that the infant's stools may 
vary greatly in 24 hours. They may vary from a bright yellow 
to a decided greenish color, and may contain minute or larger- 
sized masses, whitish in color. 

These masses may be composed entirely of casein, in which 
case they are firm and hard, or of fat, when they are soft and 
smooth. If they are fat masses they may have a casein center 
or bacteria may form the nucleus. The recognition of the char- 
acter of the ^'curd" in a movement is of importance in arti- 
ficially-fed infants. The stools of artificially-fed infants, as a 
rule, are larger in amount and lighter in color. The effect of 
carbohydrate diluent in milk is shown in the stools by the curds 
being softer and smaller than when water is used as the diluent. 

The reaction of the infant's stools fed on breast milk is usually 
acid, when fed on cow's milk is either neutral or alkaline. 

The odor of the normal breast-fed infant's stool is acid, while 
that of the artificially fed has the odor of decomposition. Thi?^ 
is especially so when animal broths are ingested. 

The bacterial flora of the infant's intestine has been the sub- 
ject of interesting study by a number of observers. 

GASTEIC DISORDERS. 

Disorders of the stomach may be functional or organic or 
reflex. One of the principal symptoms of disorders of the 
stomach is vomiting. The natural position, shape and size of 



DISEASES OF THE DIGESTIVE SYSTEM 239 

the infant's stomach makes vomiting very easy. It may be only 
a regurgitation of the food as it has been ingested, or the entire 
contents may be expelled, occurring at different periods after 
feeding. Among the causes are too-rapid feeding, impure milk 
in the artificially fed, changes in the mother's milk from various 
causes, pyloric or intestinal obstruction, ulceration of the stom- 
ach, cyclic, recurrent or periodic vomiting, and that caused by 
the acute infectious and exanthematous diseases. 

ACUTE GASTEIG INDIGESTIQ]^. 

Synonyms. Acute gastric catarrh. Acute dyspepsia. 

Acute gastritis, that caused by the swallowing of caustic or 
corroding substances, is rarely seen in infants, and its symptoma- 
tology is practically that of acute indigestion. 

Etiology. The most frequent causes of an acute indigestion 
are irregular and over feeding. Changes in the character of 
the milk may cause it ; as a single cow's-milk feeding substituted 
for a breast feeding; changes in character of the breast milk 
from nervous excitement, fear, anger, etc. ; over indulgence in 
older children at children's parties; pastries; hurried eating 
and improper mastication, as is the case when carious teeth are 
present; sudden changes in temperature; violent exercise after 
eating; too early bathing after a meal, etc. 

Predisposing causes are a prolongation of any one of the 
active causes mentioned, as irregular feeding and eating between 
meals, frequent indulgence in sweets and any condition which 
lowers vitality. 

Pathology. E"o specific lesions are present, the condition 
being functional, an arrest of secretion most likely, as well as 
muscular action. 

Symptoms. The first symptom may be languor and lassi- 
tude ; the child, if older, will lie down in preference to playing. 
Pain referred high up in the abdomen may be present, followed 
by nausea, vomiting and retching. The vomited matter shows 



240 THE DISEASES OF CHILDREN 

food as it was swallowed, perhaps some hours before, and is apt 
to be sour. 

There is always a rise in temperature, it may be slight, but is 
usually between 102° and 104° F. ; the pulse is rapid, with 
slight increase in the number of respirations. There is much 
prostration, languor and deep sleep after the cessation of the 
vomiting. I have seen repeated convulsions until the stomach 
was completely emptied. I recall one child which had a number 
of severe general convulsions at intervals for several hours, 
which ceased only after the stomach was entirely cleared out. 
The movements are apt to be abnormal, containing undigested 
food and showing signs of fermentation, are frequent, and ac- 
companied with gas and straining. The nausea may continue 
some hours after the cessation of the active vomiting. 

Prognosis. This is usually good as soon as the stomach and 
intestines are thoroughly cleared out of all undigested and irri- 
tating substances. In neglected cases, or those fed too soon 
after an attack, there develops a severe condition of the bowel 
which may result fatally. The younger the child the more 
severe the toxemia. 

Diagnosis. This is not always easy. It may be difficult to 
rule out the beginning of one of the exanthemata, which may 
be determined only by the appearance of the rash, or a pneu- 
monia, by the development of the pathognomonic physical signs. 

Treatment. The first indication is to empty the stomach. In 
an older child this may be facilitated by causing it to swallow 
a glass or so of water, cool or warm, this being ejected at once 
brings with it much offending material. If this is not possible 
the stomach should be washed. This is accomplished by a soft 
rubber catheter, 'No. 16, American, which is attached to rubber 
tube by a glass tube, with a funnel at the free end. The 
catheter is passed into the stomach, the child being held in the 
upright position or lying upon its left side upon an attendant's 
lap. In order to control its hands it should first be enveloped 
in a sheet. With the catheter in the stomach, warm water not 



DISEASES OF THE DIGESTIVE SYSTEM 241 

over 100^ F. is poured in tlie funnel, it is then lowered and the 
stomach contents siphoned out, this process being repeated a 
number of times until the wash water returns clear. 

Plain, boiled water is best though a solution of bicarbonate of 
soda can be used if the vomitus is very acid smelling. 

After the water has been returned clear for two three siphon- 
ages, from 2 to 3 ounces of water are poured in the stomach, 
the tube tightly pinched between the fingers and quickly with- 
drawn. This prevents any drops from escaping into the larynx 
as the tip of the tube slips over it. This water is nearly always 
retained and allays thirst. 

The stomach should have absolute rest for three or four hours 
after lavage, and for the first 12 hours, at least, nothing but 
water given by the mouth. After the lavage calomel should be 
given, -J grain at one dose for a child of six months, 1 grain to 
a child of one year. One grain of calomel for each year of age 
up to ^ve years, 5 grains, can be given with the greatest benefit 
in these cases. 

Even in breast-fed infants nursing should be resumed most 
carefully. The breast should be emptied regularly and the milk 
thrown away until nursing can be begun. In the artificially 
fed, milk should be returned to more slowly. 

When all nausea has ceased and the movements are improved 
2,'ive dextrinized barlev water, then whev and barlev water or 
one of the animal broths, plain or with barley water ; albumen 
water, if there is not a great deal of gas. Care should be exer- 
cised in the amount of food which is given at a feeding, at first 

1 or 2 teaspoonfuls, then -J an ounce, and, finally, the usual 
quantity taken by the child. 

But little medication is called for in these cases other than 
the calomel. Good results are often had from cerii oxalas, 

2 grains every two or three hours, where the nausea persists 
after the cessation of the vomiting. 

Should constipation follow the active symptoms, the bowels 
are best controlled by the use of enemata or glycerine supposi- 



242 THE DISEASES OF CHILDREN 

tories, rather than by the administration of laxatives or purga- 
tives, which may cause nausea or vomiting again. 

Rest in bed is most essential and the child should not be held 
or coddled. 

ACUTE GASTRITIS. 

Etiology. Any of the causes of acute gastric indigestion, if 
prolonged, may cause this condition, or if the child is in a par- 
ticularly run-down condition an acute catarrh may result in 
an acute gastritis. It may complicate the exanthemata, influ- 
enza, diphtheria or pneumonia, and is frequently secondary to 
acute inflammatory conditions of the intestinal tract. 

Pathology. The stomach may be found contracted or dilated, 
usually the former, the mucous membrane is congested, thick- 
ened, softened and covered with a thick mucus, with more or 
less food free in its cavity. Macroscopically but little can be 
detected, a small hemorrhagic area may be seen. Microscopic- 
ally the inflammation is seen to be mostly tubular, the epithelium 
is shed. 

If the inflammation is due to the swallowing of caustic poi- 
sons there are areas of ulceration, the congestion is much more 
intense and the mucous membrane more swollen. 

Symptoms. The onset is similar to that of gastric indigestion, 
pain, vomiting and .fever. The vomitus at first is food, then 
mucus, which may be blood-tinged, there is diarrhea during the 
acute stage, followed later by constipation. The temperature 
is not as high as in indigestion and gradually disappears as the 
disease progresses toward a favorable termination. The dura- 
tion of the attack is from Rve to seven days. 

Prognosis. In the robust the prognosis is good, in the weak 
and athreptic it is not so favorable. The danger in the form 
due to the ingestion of caustic substances is in a stricture of the 
cardiac orifice of the stomach. It may result in a chronic gas- 
tritis or severe inflammatory conditions of the intestines. 

Treatment. The early treatment is practically that of an 



DISEASES OF THE DIGESTIVE SYSTEM 243 

acute indigestion, rest in bed, evacuation of the stomach, even 
if resort must be had to the stomach tube. The stomach washing 
can be repeated daily or oftener, if necessary, and starvation. 

The physician must have entire control of the diet of the 
patient. Proper food must be given, and this means properly 
selected, prepared and administered, and at the proper intervals. 

Dextrinized barley water should be first given, and if tol- 
erated, in a few feedings some milk, in very small quantities, 
can be added to it, preferably centrifugal skim milk which con- 
tains much less than 1 per cent of fat. Buttermilk will fre- 
quently be tolerated when whole or skimmed cow's milk will not. 

Hydrotherapy should be used exclusively for high tempera- 
ture. If there is much thirst and the vomiting continues, a 
high saline enema will prove of service. 

Bismuth in large doses, 60 grains in the 24 hours, is a valu- 
able agent in this condition. 

I^ Bismuth subnitrat 3iiss 

Syr, rhei aromat 5i 

Aquae dest. q.s. ad Bii 
M. (Shake) 

A daily or twice daily bath should be given ; when there is a 
rise in temperature, it can be used oftener. 

CHROIsriC GASTRITIS. 

A chronic inflammatory condition of the stomach, occurring 
independently or with a similar condition in the bowels. There 
may be but slight change in the mucous membrane, the symp- 
toms being from the functional disturbances present. 

Etiology. A single attack of acute gastritis, or prolonged 
attacks may result in the chronic form. It is much more apt 
to occur in hospital infants and those who are run down from 
any cause, and in those who live in squalor and unhygienic sur- 
roundings. Any of the diseases of nutrition, as rachitis, tuber- 
culosis, anemia, are direct predisposing causes. Improper food, 
bananas, tea and coffee, pastries and sweets, may act as a cause. 



244 THE DISEASES OF CHILDREN 

Pathology. The mucous membrane is thickened and shed 
largely of its epithelium; there is much more mucous on the 
surface of the membrane than in the acute form, and frequent 
lavage is often needed before the stomach is entirely rid of it. 
It is so tenacious that a large quantity of water may be needed to 
entirely remove it. The stomach wall is thickened and the 
stomach itself distended. The solitary follicles are enlarged. 

Symptoms. Frequent vomiting without apparent cause is 
the most regular symptom, and often undigested food is vom- 
ited several hours after it is eaten. 

This is due to the interference with the motor function of 
the stomach walls from the inflammation and the distension, and 
to the perverted stomach juices. 

There are frequent attacks of colic; coated tongue, rapid loss 
in weight ; sour breath, the muscles are flabby ; the skin assumes 
a yellowish color; the bowels are constipated at first, followed 
by diarrhea; there is a loss of appetite; loss of sleep and rest- 
lessness; circulation is poor, and extremities cold. The child 
may live for a long while, wasting rapidly and die suddenly 
at the end, when death has hardly been expected. 

Prognosis. In general this is not good, unless the physician 
has constant and direct control of the diet, hygiene and life of 
the child. Intestinal involvement influences the prognosis. Re- 
covery is slow. 

Diagnosis. The principal condition to be borne in mind is 
that of pyloric stenosis, considered in another place (see page 
234). Chronic gastritis is not apt to occur in the newly -born, in 
whom pyloric stenosis is most of ten seen. 

Treatment. As already stated the physician must be in con- 
trol of the child as to its habits, hygiene, mode of life and diet. 
A change of climate is often of the greatest benefit. Stomach 
lavage daily, then every other day until vomiting is relieved, 
should be practiced. These patients should live out of doors 
at all seasons, well protected by flannel band and underwear, 
and outside wraps in winter. The feet should be frequently 



DISEASES OF THE DIGESTIVE SYSTEM 245 

inspected and hot-water bottle used if needed. Woolen stock- 
ings should be worn. Daily tub baths, folloAved by a cocoanut- 
oil rubj should be given. The hygienic care should include the 
frequent change of napkins as soon as soiled or wet, and their 
proper cleansing. 

The diet is most important. If breast fed an analysis, as 
complete as possible, must be made of the mother's milk. If 
over rich in fat, an attempt made to regulate this ingredient. 
If, in spite of every effort to change the character of the milk, 
the vomiting continues a w^et nurse, whose baby's age approxi- 
mates the patient's may be procured. If this is unsuccessful, 
resort should be had at once to a modified milk, at first prac- 
tically eliminating the fat content. This can best be done by 
utilizing a centrifugal milk in which the fat has been reduced 
below 1 per cent, or a fat-free buttermilk made with the lactone 
tablet can be used. If this is retained the prescription can be 
increased slowly by addition of .25 per cent of fat daily, or 
every other day, until 2 per cent has been reached, unless vom- 
iting recurs when the fat-free mixture is again used. 

Fat-free whey diluted with equal parts of barley water is 
frequently well borne. The first essential in regard to the milk 
is that it should be either certified or inspected. 

If milk is not tolerated in any form, after lavage, give dex- 
trinized barley water in small quantity, by gavage at first, then 
in 2 or 3 teaspoonful quantities, gradually increasing the 
amount. 

The animal broths are frequently well borne, or beef juice, 
expressed immediately before feeding and diluted with quite 
warm water to prevent its coagulating. 

It may be necessary to continue the use of gavage for several 
days. 

One great mistake is made in these cases in trying so many 
foods in a short space of time. Kind neighbors and friends 
harass the mother frantic by suggestions as to this or that food, 
and the physician is asked in regard to each new one in turn. 



246 THE DISEASES OF CHILDREN 

It is a mistake to believe these atlireptic infants need alcohol. 
It is the worst remedy which can be used, and is responsible for 
much trouble. In giving the proprietary preparations panopep- 
tone and peptonoids^ their alcoholic ingredients to 2 per cent, 
must be remembered. 

If the vomitus is very sour good results are sometimes ob- 
tained from the use of bicarbonate of soda in the wash water 
in the proportion of a teaspoonful to the pint of water. 

But little medication is needed or can be given in these cases. 
Save the stomach for food which is most needed. Fowler's 
solution of arsenic is of service, in drop doses in water three 
times a day, and strychnia sulphate, gr. 1/200, to a child of one 
year, assists in toning up the stomach muscle. 

If constipation is present it can best be controlled by use of 
enemata and glycerine suppositories, alternated, each morning 
at the same time, the child being placed on its chair immediately 
after its use. 

GASTRIC DILATATION GASTRECTASIA. 

This condition should be differentiated from an enlarged ab- 
domen, so-called pot helly , yThich is so frequent in yearlings or 
during the second year, this most often being due to a dilata- 
tion of the colon. 

Etiology. The most frequent cause in new-born babies is 
pyloric obstruction or stenosis. The next is a stretching of the 
muscular wall due to fermentation and decomposition of the 
food contents, as occurs in chronic gastritis. It is a manifesta- 
tion of general nutritional disorders as in rachitis and tuber- 
culosis. Frequent attacks of acute indigestion; too frequent 
eating and improper foods are also causes. 

Pathology. The changes in the stomach vary in these cases, 
as found postmortem ; often great evidences of chronic gastritis 
are present. The degree of dilatation also varies, as postmortem 
change may show considerable contraction in a stomach which 
had been shown to be enlarged before death. 



DISEASES OF THE DIGESTIVE SYSTEM 247 

Symptoms. These are as outlined in the previous section in 
chronic vomiting; sluggish circulation; waxy color; cold ex- 
tremities; thirst; poor appetite; coated tongue; high-colored 
urine. Percussion shows an increased area of stomach resonance, 
perhaps below the umbilicus, and this is confirmed by intro- 
duction of water slowly through the stomach tube to point of 
tolerance. Air injected into the stomach should never be em- 
ployed as a diagnostic procedure in a child because of the danger 
of rupture of the stomach. 

Prognosis depends upon the cause, and if not organic upon 
the early diagnosis and its early removal. 

Treatment is practically that of chronic gastric catarrh. Re- 
lieve the stomach of its fermenting contents, with sufficient wash 
water to have it return entirely clear. Wash daily at first then 
twice and finally once a week, continuing several weeks at least. 
Small quantity of food, predigested at first, at two or three 
hourly intervals, liquids entirely at first. 

'Nwx vomica, 1 or 2 drops of the tincture to a child of two 
years three times a day, well diluted, is beneficial. Careful 
attention to the bowels, the wearing bf an abdominal binder; 
daily baths, and general rubbing will be found very beneficial. 

CYCLIC VOMITIITG. 

Known also as recurrent or periodic vomiting. It is a condi- 
tion characterized by severe vomiting and prostration with but 
little f ever^ as a rule, in which no active cause, as indiscretions of 
diet, can be traced. 

Etiology. This is obscure and has been the subject of much 
conjecture. It is doubtless due to an increased acidity of the 
fluids of the body from some disturbance of elimination and 
absorption. There is an acetone odor to the breath, and symp- 
toms of a toxemia. There seems to be a fairly uniform decrease 
in uric acid elimination. The basis of the trouble seems to be 
a disturbance of metabolism rather than an error of digestion. 



248 / THE DISEASES OF CHILDREN 

My own cases have failed to reveal any uniform digestive dis- 
turbance preceding tiie attacks, or any special article of diet 
as responsible for them. The starchy foods have been thought 
by some to be a cause. 

Symptoms. Cyclic vomiting rarely occurs in infancy, but 
is more frequently seen in children between 5 and 10 years of 
age. My cases have been about evenly divided in the sexes, 
though girls are said by some observers to be most often affected. 

The onset is usually sudden, and without any dietary indiscre- 
tions. The vomiting may begin in the night, or the child wakens 
in the morning, heavy and dull, and complains of nausea, per- 
haps of pain in the abdomen, which is soon followed by vom- 
iting. If vomiting occurs at night the supper may be vomited 
undigested, if later in the morning, the first vomitus may be only 
fluid. The child continues to vomit at frequent intervals, with 
retching between, the vomitus being principally mucus, perhaps 
bile-stained and a few streaks of blood. Any attempt to admin- 
ister medicine, food or water results in its rejection at once. 

As a result of the continuous vomiting and retching, pros- 
tration develops early, the pulse is accelerated, the child drops 
back after each attack prostrated, the face is pallid, the eyes 
sunken, lips and tongue parched, the latter coated; abdomen 
retracted, urine highly colored and scant, and the characteristic 
sweetish or acetone odor to both the urine and the breath. 

As a rule there is no temperature, though in one of my cases 
the temperature rose to 102° F. in a number of attacks. Con- 
stipation is the rule, though usually a movement can be obtained 
by an enema. 

The duration of the attack is always 30 to 48 hours, and it 
may last for three or four days. The frequency of the vomit- 
ing is gradually lessened as the disease progresses, and I have 
seen a child in an hour's time after severe vomiting call for 
water and retain it and everything given subsequently. There 
is no regularity as regards the time of the recurrence of the 
attacks. One of my cases, under observation for two years or 



DISEASES OF THE DIGESTIVE SYSTEM 249 

more, had a recurrence on an average of once every four months, 
though not regularly at that interval. In this case the attacks 
were undoubtedly rendered less severe and more infrequent 
by the alkaline treatment. 

Diagnosis. The diagnosis must be made between meningitis 
and organic lesions of the kidney. The failure of brain symp- 
toms to appear eliminates meningitis from consideration, though 
it should always be thought of. Urinary analysis is of im- 
portance in ruling out kidney lesions, and this is a diagnostic 
aid which is too frequently overlooked. 

The presence of acetone in the urine is confirmatory evidence 
of cyclic vomiting. Among the tests for acetone are the 
following :* 

1. lieben's Iodoform Test, as modified by Kalfe, is as fol- 
lows: 20 grains of potassium iodide are dissolved in a drachm 
of liquor potassge and boiled; the urine is then floated upon the 
surface of the fluid in a test tube. At the point of contact a 
precipitation of phosphates occurs, which, if acetone be present, 
becomes yellow and studded with yellow points of iodoform. 

A more delicate method of application of this test is to first 
distill a small quantity of the urine and apply the test to the 
distillate. This test has one disadvantage: lactic acid and ethyl 
alcohol behave with it similarly to acetone. 

2. Chautard's Test. A drop of aqueous solution of magenta 
decolorized by sulphurous acid gives, with fluids containing 
over 0.01 per cent of acetone, a violet color. This appears in 
dilute solutions after four or five minutes. 

3. Le Noble's Test. On adding an alkaline solution of so- 
dium nitroprusside — so dilute as to have only a slight red tint — 
to a fluid containing acetone a ruby-red color is produced, which 
in a few minutes changes to yellow, and on boiling, after adding 
acid, to greenish-blue or violet. A quarter of a milligramme of 
acetone can be thus detected. 

* Purdy: "Practical Uranalysis. " 



250 THE DISEASES OF CHILDREN 

4. Baeyer's Indigo Test. A few crystals of nitrobenzalde- 
hyde are dissolved by heat in the suspected urine ; on cooling 
the aldehyde separates in the form of a white cloud. The mix- 
ture is thus made alkaline with dilute sodium solution, and, if 
acetone be present, first yellow, then green, and lastly an indigo- 
blue color will appear within 10 minutes. 

5. Reynold's Test. This test depends upon the fact that 
acetone promotes the solution of mercuric oxide. The test may 
be conducted as follows : The yellow precipitate of mercuric 
oxide, obtained by the reaction of mercuric chloride with an 
alcoholic solution of potassium hydrate is added to a small 
quantity of the urine, which is shaken and filtered. To the clear 
filtrate ammonium sulphate is carefully added, and if acetone 
be present some of the mercuric oxide is dissolved and a black 
ring of sulphide of mercury appears at the plane of contact be- 
tween the two liquids. 

Prognosis. A few cases have been reported, with fatal ter- 
mination, but these are very unusual. They recover in from 
two to four days. 

Treatment. Active treatment during the attack is of no ser- 
vice. !N'othing should be given by the mouth except perhaps 
a preliminary draught of water for the purpose of washing it 
out as it is immediately vomited. The best results are obtained 
from high rectal injections, first for the purpose of evacuation 
and followed by an injection of a solution of bicarbonate of 
soda, 2 drachms to the pint, with the purpose of having it re- 
tained. These enemata should be alternated at four-hour inter- 
vals with predigested niilk in quantities not to exceed 4 ounces 
given through a catheter into the sigmoid if possible. 

If the retching is very severe and the prostration extreme, 
the use of codeine sulphate, grain -|, to a child of five years, or 
morphia sulphate, grain 1/32, will give good results. 

As soon as the vomiting ceases and the child asks for water 
it can be given tentatively. Crushed ice at first, small quantity 
of water, and repeated in larger amounts at short intervals, 



DISEASES OF THE DIGESTIVE SYSTEM 251 

then a broth followed by diluted skimmed milk. As soon as 
possible a cathartic should be given, cascara or a part of a 
bottle of citrate of magnesia. 

In the interval between the attacks, the regular administra- 
tion of bicarbonate of soda in 3 grain doses, four times a day, 
over a period of three or four weeks, with a week's rest, and a 
resumption of it at the end of that time for another three weeks, 
and so on for four months, will lengthen the interval between 
attacks. 

The diet should be a mixed one, a very moderate amount of 
meat, and sparingly of cereals, otherwise the diet is not 
restricted. 

If an attack seems imminent the dose of soda should be in- 
creased to double, 6 grains every three hours. 

Some children cannot be persuaded to take the soda by the 
mouth. This was the case with one of my patients who readily 
submitted to its administration twice daily in an enema. 

If there is a history of rheumatism the salicylates should be 
given but not as a routine. 

GASTEALGIA. 

A sudden and severe pain in the abdomen, principally in the 
epigastrium, which cannot be traced to an indiscretion in the 
diet or any definite lesion of the viscera. 

It is considered to be a neurosis, a neuralgia affecting the 
nerves of the stomach. 

We know nothing which is definite of the etiology or path- 
ology of this condition. It is more than likely associated with 
the rheumatic diathesis, whatever that may be. 

Diagnosis and Symptoms. The symptoms of gastralgia are 
best considered under the head of differential diagnosis. 

Children, as a rule, do not locate pain accurately, hence when 
a pain is referred to the epigastrium other conditions may be 
present which may have pain as a principal symptom, but re- 
ferred to near or remote organs. Among these may be men- 



252 THE DISEASES OF CHILDREN 

tioned a diaphragmatic pleurisy, pneumonia with small pleural 
involvement, vertebral caries of the middorsal region, intercostal 
neuralgia, the pericardium or endocardium, the appendix. 

An investigation of the regions giving rise to these conditions 
will usually rule out the more serious conditions. The pain 
in a gastralgia is usually more or less spasmodic, entire relief, 
except perhaps a slight feeling of soreness being experienced in 
the interim between attacks. Rarely there may be nausea, and 
more rarely vomiting caused by the pain entirely, and with no 
signs or symptoms of indigestion. 

Treatment. Rest in bed; heat, either moist or dry, over the 
abdomen and epigastrium; counter irritation by a sinapism of 
mustard or turpentine stupe and hot water internally, in which 
has been put a few drops of camphor. During the interim put 
the child on tonic treatment. Fowler's solution in gradually 
increasing doses of a drop at a time, until the point of toleration 
is produced, and change of food, scene and air. 

ACUTE GASTKOEI^TEEIC INFECTIOIS'. 

In this form of disturbance there is usually diarrhea accom- 
panied by gastric irritation, either nausea or vomiting or both. 
There is always a causal relation between the food in jested and 
the development of this condition, infected milk being most 
frequently the cause in the artificially fed. Statistics universally 
show the highest mortality rate among bottle-fed children during 
the first year. It occurs in the breast fed from improper and 
irregular feeding, and frequently in those partly nursed and 
partly artificially fed. It is most often seen in the hot summer 
months though it may occur in winter. 

Etiology. Milk in the various steps of its handling from 
the cow to the consumer is more frequently contaminated than 
any other article of food, and being an excellent culture medium 
both pathogenic and non-pathogenic organisms develop with 
great rapidity if conditions are favorable. The toxins devel- 



DISEASES OF THE DIGESTIVE SYSTEM 253 

oped by the bacteria in the milk before and after ingestion are 
responsible for the majority of the symptoms present as well as 
for the invasion of the bacteria in the intestinal wall. 

Many organisms have been identified in examination of 
stools from children affected with gastroenteric catarrh or in- 
fection. The coli group is most often identified, and Escherich 
has shown that this group can develop great virulency. Strepto- 
cocci are also found, especially the streptococcus enteritis which 
Booker claims is of great importance as a causative factor. 

Many other bacteria are found among which may be named 
the bacillus subtilus, bacillus pyocyaneus, proteus vulgarus. 

Pathology. One w^ho does much postmortem work in these 
cases will be impressed at once with the small amount of 
macroscopic changes occurring in the stomach and intestine 
with the history of such severe symptoms during the last illness. 

Microscopically there is found a loss of epithelium in both 
stomach and intestine, and a general infiltration of the epithe- 
lium. Deep ulceration may rarely be found. The mucous mem- 
brane exhibits, as a rule, a washed-out appearance with here 
and there a reddened area, some mucus adhering to surface of 
the membrane, and the intestine practically empty of contents. 

The small gut will often be found contracted almost through 
its whole extent. 

Symptoms. Usually without warning the child will vomit, 
often large quantities, apparently much more than had been 
taken at the last feeding. In older children there is apt to be 
nausea for some time after the initial vomiting. There is con- 
siderable prostration, the child looks sick, is pale and restless. 
The temperature rises quickly and may be 102° or 103° F. The 
stools may at first be normal but are followed by undigested, 
offensive ones full of mucus. 

In the very young improvement is usually quite prompt or 
the child may quickly succumb, or the condition develop into a 
chronic one. 

Prognosis. In previously normal and healthy children the 



254 THE DISEASES OF CHILDREN 

prognosis is usually good, but in the athreptic baby recovery 
is not so prompt; and serious sequelae are apt to develop. 

Treatment. As in other gastroenteric disorders the treatment 
is best considered under 1, Dietetic ; 2, Medicinal ; 3, Hygienic. 

1. Dietetic. First all food should be immediately withheld, 
especially milk, for at least 24 hours. While the nausea lasts, 
no food by the mouth can be retained or assimilated. Milk in 
any form should not be given, as no other food offers so favorable 
a culture medium for bacterial development when taken into 
the stomach. Dextrinized barley water is better taken care of 
than anything else, and can be given in small quantities at 
the end of 24 hours, or later, if the nausea and vomiting have 
not stopped by that time. To the barley water can be added 
a little beef peptonoids or panopepton which makes it more 
palatable to some, and nutritious also. 

On the third day one of the animal broths, plain or with 
barley water, can be given, and upon the return of normal 
stools, practically free from mucus, milk can be resumed, at 
first in the form of whey, made from fat-free milk, and to this 
may later be added small amounts of skimmed milk, until the 
usual formula can be resumed. The first milk given may be 
in the form of buttermilk, made from fresh milk by the addi- 
tion of the pure culture lactic acid bacteria, and it is frequently 
well taken by children. 

2. Medicinal, If much nausea is present, calomel, dry on 
the tongue, is the remedy of all others. To a child of one year 
give 1 grain of finely-triturated calomel. If not much nausea 
is present and the stools show intestinal irritation early a dose 
of castor oil should be given in order to quickly sweep out the 
decomposing and putrid intestinal contents. 

If much gastric irritation is present and neither remedy can 
be retained, lavage of the stomach gives brilliant results. 

If the initial purgative is given early and the dietetic treat- 
ment outlined, strictly followed, further medicinal treatment is 
usually not needed, but if the intestinal irritation continues 



DISEASES OF THE DIGESTIVE SYSTEM • 255 

several doses of bismuth subnitrate may be indicated. The fol- 
lowing can be used to advantage : 

I^ Bismuth subnitrat oss 

(Merck or Squibb) 
Syr. rhei aromatici 5 ui 

Aquae destillatae q.s. ad oiii 
M. (Shake weU.) 

Sig. One teaspoonful every two hours, until at least six doses have been 
given. 

To this prescription can be added 5 grains of tannalbin to 
each teaspoonfnl if the mncus persists and the evacuations are 
very frequent. 

Colon irrigation with the normal salt solution is of great ben- 
efit, especially early when the nausea and vomiting are features 
and there is so much loss of fluids. 

3. Hygienic Treatment. The most important hygienic 
treatment consists in the proper care of the food of the child 
from its production until it is consumed; the proper care of 
the bottles and nipples and the correct modification of the milk 
for the individual child. Most of these attacks are preventable, 
and if the parent is correctly informed of the dangers attending 
carelessness of detail in the preparation and handling of the 
child's food, a great deal of mortality and morbidity will be 
prevented. 

The child should be warmly clothed, wearing an abdominal 
binder at all times. It should live out of doors, well protected 
in inclement weather in winter. Daily baths are most impor- 
tant, and during an attack hydrotherapy for pyrexia is specially 
indicated. Great care should be taken of the napkins, which 
should be boiled before using a second time. Regular feeding, 
according to schedule, is most important and should be insisted 
upon. It is of as much importance to give accurate written 
directions in regard to the preparation, care and administration 
of the food as it is for medicine. Do not take anything for 



256 THE DISEASES OP CHILDREN 

granted when it comes to the feeding of an infant, especially 
during convalescence from an active gastroenteric infection. 

CHOLERA INFANTUM. 

Definition. This term is erroneously applied to many cases 
of acute gastrointestinal disturbances, which do not at all answer 
the description of this pathologic condition. It is a disease seen 
in children under three years of age, and is characterized by 
great prostration, very rapid wasting, profuse watery discharges 
from the bowel, vomiting of large quantities of fluid, and either 
rapid improvement as a result of treatment or early death. 

Etiology. 'No specific organism has been isolated, but the 
symptoms are those of an essentially toxic disease, viz., rapidly- 
appearing prostration, high fever, profuse diarrhea and 
vomiting. 

Pathology. It is surprising that a condition giving rise to 
such severe symptoms will result in so little gross pathologic 
changes. 'No constant changes are found in any organ. The 
intestines are collapsed and show a pale washed-out appearance 
with a denudation of the superficial epithelium. The thin in- 
testinal contents have a yellow color and musty odor. 

Symptoms. This is usually not a primary disease occurring 
during the convalescence from an acute gastroenteric disorder. 
There is usually sudden, violent and profuse vomiting, at first 
the contents of the stomach followed by a fluid vomitus and 
considerable retching. A diarrhea soon follows, fecal in char- 
acter at first, the discharges soon becoming entirely fluid, soak- 
ing through napkins and protecting cloths as soon as passed. 
They occur very frequently, every half hour or so, have a musty 
odor, and are practically colorless. But little mucus is passed 
as a rule. 

There is a rapid wasting, the skin is cool, pale and trans- 
parent, and soon becomes wrinkled from the wasting; eyes are 
sunken and rolled up ; the child lies at first listless and takes no 



DISEASES OF THE DIGESTIVE SYSTEM 257 

notice of its surroundings, but later is very restless. The tem- 
perature rises rapidly, reaching 103° to 105° or 106° F. in a 
short while. Rarely cases may be seen in which the temperature 
does not rise much above normal, if at all, and it is in these 
that the prognosis is so much graver. The pulse is feeble, rapid 
and without volume, the respirations are hurried and shallow, 
the tongue is at first coated but later is denuded of epithelium 
and becomes red and dry. The abdomen is retracted ; the urine 
scanty ; the fontanelle depressed ; there is great thirst but water 
is usually vomited at once after swallowing. Later there may 
be a shrill cry which is suggestive of meningeal irritation. 

Prognosis. The prognosis is grave in all cases of cholera 
infantum, no matter how slight they may appear to be in the 
beginning. 

The duration is short, improvement either being very prompt, 
or a fatal termination inevitable in 24 or 48 hours. Excessively 
high or a very low range of temperature are grave signs. Some 
infants die within 12 hours in spite of early and scientific 
treatment. 

Diagnosis. ]^o other condition met with in the o^astrointes- 
tinal disorders in children presents so severe a picture of serious 
illness. The association of severe vomiting, profuse diarrhea, 
rapid wasting, high temperature and prostration is sufiicient for 
a diagnosis. 

Treatment. The indications for treatment are very positive, 
viz., to withhold all food, clearing out of the stomach by stomach 
washing, and the bowel by purgation and enteroclysis, anti- 
pyretic measures, baths or packs. If the wasting diarrhea keeps 
up, the indication is very positive for the hypodermic admin- 
istration of morphia and atropia. Give morphia in dose of 
1/100 grain to child of one year and repeat for its effect. 
Atropia can be given in 1/600 grain and repeated as indicated. 

Enteroclysis and hypodermoclysis are indicated to renew the 
fluids lost in the profuse watery diarrhea. Hydrotherapy should 
be used for the pyrexia, putting the child in the water at 100° E. 



258 THE DISEASES OF CHILDREN 

and cool gradually to 85^ or 90^ E., being careful to use friction 
of extremities and body wkile in the water. Cold compresses 
should be applied to the head and renewed at frequent intervals 
during the bath. If the temperature is below normal hot water 
should be added to the bath to 110° P. The baths should be pro- 
longed for at least 5 minutes. The addition of mustard to the 
bath water is beneficial. Antipyretic drugs should not be used 
under any circumstances. If stimulation is needed it should 
be used hypodermatically, as it is not safe to rely upon the stom- 
ach for absorption. JSTo drug will give quicker results than 
camphor dissolved in olive oil, gr. xx to gi, and of this solution 
giving 10 or 15 minims hypodermatically. The effect of cam- 
phor is quick but transitory, and should be repeated or supple- 
mented by brandy or digitalis or strophanthus, 1 or 2 minims 
of the tincture of either preparation with the brandy. 

^o food should be given by the mouth until all nausea and 
vomiting have ceased and the diarrhea is checked. Small quan- 
tities of sterile water can then be given, 2 teaspoonfuls at a time 
every 15 or 20 minutes, and usually this is taken ravenously. 
If retained a small quantity of dextrinized barley can be given 
to which has been added a few drops of brandy or a small quan- 
tity of panopepton or peptonoids. If the child soon tires of 
barley water, gruels made from the other cereals can be tried, 
rice, granum, wheat flour, etc. Later the animal broths can be 
tried, and last a diluted skimmed milk, adding 1 teaspoonful to 
a feeding of gruel, and gradually increasing. The milk should 
best be Pasteurized at first. A rise in temperature with a return 
of the diarrhea or vomiting after the resumption of a milk 
feeding, is evidence enough that the milk should be discontinued 
at once, and a purgative given to wash out the undigested masses 
and the same routine again begun. 

If the same experience is encountered on again giving cow's 
milk, condensed milk should be tried, as this is low in fat per- 
centage, and often can be taken care of when modified cow's 
milk cannot. 



DISEASES OF THE DIGESTIVE SYSTEM 259 

The termination of these cases is either in prompt recovery, 
early death or a development of a severe enterocolitis. 

ACUTE ENTEROCOLITIS. 

Synonyms. Ileocolitis; dysentery; enteric infection; inflavi' 
matory diarrhea and enteritis. 

In this condition there are more or less severe changes occur- 
ring in the intestinal mncoiis membrane, -usiially without in- 
volvement of the stomach. 

Etiology. This trouble is rarely primary, following, as a 
rule, upon some one of the acute forms of gastric or gastrointes- 
tinal disorders. 

The Shiga bacillus is very often found, also the colon bacillus 
and streptococcus. Age plays an important part in the etiology. 
It is most frequent during the second year, or the much-dreadecl 
"second summer," not because the teeth are being cut at this 
time but because the child is allowed to eat a too liberal diet 
during this period and acute gastrointestinal troubles follow. 
It may complicate the acute exanthemata or pneumonia. Bottle- 
fed babies are prone to develop this condition! 

Pathology. As implied by the name given this trouble, the 
process is limited largely to the colon and the lower portion of 
the ileum, in a small percentage only the colon may be affected. 
The stomach may show signs of catarrhal inflammation but as 
a rule is normal. Three grades are usually described, the mild, 
or acute catarrhal; ulcerative; and pseudomembranous. 

1. Catarrhal. One is impressed with a condition seen in 
autopsy work in fatal cases of catarrhal enterocolitis, viz., the 
comparatively slight changes seen macropscopically in the intes- 
tines. The stomach and upper part of the small intestine will 
show changes varying from a very slight congestion here and 
there, with small amounts of mucus loose in the bowel, or bath- 
ing the surface of the mucous membrane, to a deeply-congested 
area at frequent intervals. The deeply-congested areas are 



260 THE DISEASES OF CHILDREN 

found at or near the cecum. Pyer's patches are swollen, and 
the general surface of the mucous membrane appears granular. 
On section the mucous membrane shows a loss of superficial 
epithelium in some places perhaps approaching the ulcerative 
stage. There is a general round-cell infiltration of the mucous 
membrane causing thickening and some swelling of the lymph 
nodes. 

2. Ulcerative. In this form there may be a follicular ulcer- 
ation, being limited to the solitary follicles or a coalescence of 
a number of these forming a large ulcerated area. The ulcera- 
tion may also involve a large area and be of a catarrhal variety 
entirely, and quite superficial. Ulcers are rarely found above 
the lower 12 or 15 inches of the ileum, and are chiefly located 
in the colon. In those areas where the follicles have coalesced 
the destructive process is deep, penetrating to the muscular coat, 
but in the milder form it is superficial. The mucous membrane 
has a pitted appearance. 

3. Pseudomembranous. In this form also the process is 
chiefly located in the lower ileum and most of the colon. There 
is a general thickening of the intestinal wall, due to round-cell 
infiltration, congestion and attachment of the pseudomembrane. 
The whole surface of the colon may be covered with membrane 
or only a portion of it, with deeply-congested areas here and 
there, from which the membrane has become detached. The 
process is rarely found in patches, but it may be limited to the 
extreme lower end of the colon and the rectum. 

The pathological changes found elsewhere depend entirely 
upon the complications existing during the attack. It is not 
an unusual thing to have a patchy bronchopneumonia, especially 
in the prolonged cases, and in those who are reduced in vitality, 
the athreptic, marasmic child being much more liable to develop 
such complications. Nephritis may very rarely occur as a 
complication. 

Symptoms. Clinically, it is often very difiicult to differen 
tiate the three varieties of this condition described under path 



DISEASES OF THE DIGESTIVE SYSTEM 261 

ological changes. I have seen cases with a large number of 
mucous, bloody stools, with other symptoms indicating a severe 
ulcerative type, in which the autopsy findings did not reveal any 
ulceration of the type expected. 

If primary, an enterocolitis usually begins suddenly, with 
vomiting, a rise of temperature varying from 102° to 104° F., 
with proportionate increase in pulse rate, and the child appears 
sick from the onset. 

The vomiting as a rule is not severe or often repeated, and is 
soon followed by abnormal evacuations. The first part of the 
first stool may be normal, the last loose, perhaps containing 
undigested food and mucus. The character of the movements 
rapidly change, they are frequent, perhaps averaging once an 
hour ; thin, contain much mu.cus, and vary in color from a very 
dark yellow to many shades of green. Some of the stools may 
consist simply of glary mucus. They may or may not, in the 
severe cases, contain blood varying from a few streaks in the 
mucus to a larger quantity. The stools will change in color, 
after being passed, and Avhen napkins are examined the hour it 
was soiled should be known. After standing they frequently 
become very green in color, turning from a light brown to a 
very much lighter shade of green. Frequently there is tenesmus 
with each stool, the rectal mucous membrane may protrude as 
the child strains. The mother will often state that water or 
nourishment of any kind "passes directly through,'^ meaning 
that the ingestion of anything causes peristalsis and a move- 
ment results. If there is much toxemia and high temperature 
the child will probably lie in a stupor ; with a lower temperature 
it is apt to be fretful and restless. 

It is not infrequent that they have muscular twitchings or 
general convulsions. 

The high range of temperature is usually of short duration, 
there being an elevation of 2° or 3° F. during the rest of the 
acute stage. As a result of the toxemia, frequent loose actions, 
long febrile course and restricted diet ] there is rapid wasting, 



262 THE DISEASES OF CHILDREN 

the eyes become sunken, the skin is wrinkled and the fontanelle 
sunken, the picture presented being anything but a promising 
one. Thirst is apt to be a prominent symptom. 

Duration. The duration in the severe form of enterocolitis 
is usually comparatively short, the child growing rapidly worse 
from the onset, terminating fatally within a week or 10 days, 
or the acute symptoms subside and the convalescence is pro- 
longed for several weeks, or an improvement follows promptly 
from the acute symptoms and the child succumbs to a compli- 
cating bronchopneumonia. 

Cases may terminate fatally in three or four days, in spite 
of diet and treatment. 

Milder cases are more often seen, but the general symptomat- 
ology is the same, a less abrupt onset, not so frequent vomiting, 
fewer stools, but they have the same general characteristics, ner- 
vous symptoms less marked, and convulsions unusual, and the 
general duration is shorter. The acute symptoms usually end 
in about a week, and the convalescence while slow is steady. 
Indiscretions in diet result in very frequent relapses and a 
chronic enterocolitis is the natural sequence. This is especially 
true when milk feedings are resumed too quickly and in pre- 
scriptions too rich in both fat and proteids. 

Prognosis. Several factors materially influence the prognosis. 
The younger the child the more grave the prognosis ; severe 
attacks under six months are usually fatal. 

Artificially-fed infants bear an attack poorly ; in the athreptic 
and poorly-nourished the results are poor; cases in which a 
digestive disturbance has been neglected always do badly, hence 
the prognosis is decidedly better when treatment is begun 
promptly. 

Treatment. As just stated, on the promptness with which 
treatment is instituted in these cases depends in a great measure 
the results. The treatment can be considered under four heads ; 
1, preventive treatment; 2, general and dietetic treatment; 
3, medicinal, and 4, hygienic treatment 



DISEASES OF THE DIGESTIVE SYSTEM 263 

. 1. Preventive, l^eglect of apparently trivial attacks of 
gastroenteric distnrbanceSj continuance of the usual diet in the 
presence of what is generally considered a trivial attack of vom- 
iting and diarrhea, is responsible for more of these cases than 
any other cause^, and undoubtedly increases the mortality 
greatly. 

Mothers should be educated in the first place in the impor- 
tance of a pure milk supply in the artificially fed, the value of 
absolute cleanliness in the care and preparation of the child's 
diet; the necessity for the immediate withdrawal of all food 
upon the first appearance of vomiting or an abnormal stool and 
early medical treatment. If these requirements were met in all 
cases, the frequency of the severe cases and the mortality would 
be greatly reduced. 

2. General and Dietetic. If the vomiting is recurrent the 
stomach should be washed, using warm, filtered and boiled 
water. If on a general diet or modified or whole milk, all food 
must he withdravm at once, and not resumed until both the stom- 
ach and intestines have had a rest, and then resumed very grad- 
ually. The first food given should be a dextrinized plain barley 
water or combined with any of the animal broths, in equal parts, 
or a small quantity of panopepton or liquid peptonoids. The 
latter are of value chiefly because of their alcohol content, having 
relatively small food values. Milk can be resumed after the 
subsidence of the symptoms by the use of whey, made from fat- 
free milk, combined with barley water or a diluted fat-free 
buttermilk made with a pure culture of lactic acid bacteria. 
Beef juice has a tendency to increase the diarrhea, often causing 
watery movements. The food must be changed from time to 
time also, as the child is apt to become tired of one or two of the 
combinations mentioned. If it refuses food entirely, it must 
be given by gavage. Do not resume milk feeding too suddenly; 
add 1 or 2 drachms of skim milk to a barley-water feeding, 
once during the day; if this is taken care of give the same 



264 THE DISEASES OF CHILDREN 

quantity twice the next day, the next give 2 teaspoonfuls, and 
so on, gradually increasing the milk. 

A valuable agent, but a much-abused one in these cases, is 
colon irrigation. It need not be used oftener than twice in the 
24 hours, once being usually sufficient ; a soft ^elaton catheter, 
well anointed, should be used, and if there is much straining 
and a tendency for the bowel to expel the tube, the irrigating 
bag should be held but a small distance above the buttocks. If 
there is much mucus of the white, glary kind, the irrigation can 
be of an astringent solution to advantage, a heaping tablespoon- 
ful of tannic acid, dissolved in a quart of water. Eor an ordi- 
nary irrigation use the normal salt solution, using not less than 
2 quarts at one irrigation. The temperature can be as low as 
85° F. in febrile cases, or 95° to 98° F. where the temperature 
is not so high. Tub baths are given for cleansing purposes as 
a routine, but should be repeated as an antipyretic measure. 
Medicinal antipyretics should never be used. 

3. Medicinal. Shotgun diarrheal prescriptions should never 
be given. Only such drugs should be used as there is a special 
indication for. As soon as the first symptoms appear a purga- 
tive must be given, castor oil, if the stomach is in condition to 
retain it, otherwise calomel, in 1 grain dose to a child of one 
year or over. One of the most useful is bismuth and a pure 
subnitrate preparation is advised. The usual dose given by 
the average practitioner is much too small. It should be given 
in not less than 10 grain doses until at least 60 to 80 grains 
have been taken in 24 hours. It is a valuable agent, acting 
mechanically on the congested and inflamed mucous membrane. 
An astringent can be added if the movements are very frequent 
and contain much mucus. Tannalbin or tanningen in 3 to 5 
grain doses can be added to the bismuth for their astringent 
effect. If there is much odor to the evacuations salol will be 
found of service, given in 2 to 4 grain doses every four hours. 

Stimulation may be needed, but should be reserved for active 
indications. 



DISEASES OF THE DIGESTIVE SYSTEM 265 

Opium is of service in those cases with very frequent move- 
ments and a great deal of tenesmus. Dover's powder, in J to -J 
grain doses, is a valuable remedy. Opium in any form should 
not be combined with a prescription, but ordered separately and 
given at the same time if need be. This is important, as the 
opium is usually the first remedy to be discontinued. Kerley 
has recommended the addition of 1 grain of sulphur to the bis- 
muth preparation, if the movements do not turn black after its 
administration for a few days. For the tenesmus, 3 or 4 drops 
of the deodorized tincture of opium can be given in 2 or 3 
drachms of starch water as an enema, following an irrigation, 
if the Dover's powder is ineffective. 

The after-care of these patients is most' important. Medica- 
tion in convalescence is not specially indicated, as they usually 
respond quickly to proper diet as soon as it is safe to resume it. 

4. Hygienic. In no class of cases does a complete climatic 
change have so beneficial an action as in children convalescing 
from enterocolitis. From points south of Mason^s and Dixon's 
Line no other change is more beneficial than removal to points 
in Michigan. The large amount of water through this State 
imparts a life-giving something to the air which works wonders 
in these cases. They unquestionably get back upon a gaining 
diet much quicker in this climate than at home. Some cases do 
well when simply moved from the city to the country nearby — 
others do better in the mountains or at the sea shore. 

Great care should be exercised in keeping the soiled napkins 
clean. They should be boiled daily. In institutions the nap- 
kins from the well should be treated separately from the in- 
fected ones. These cases should be isolated in hospitals and 
institutions, and not too many kept in a ward or room. Their 
feeding utensils should be kept apart from the general supply 
and frequently boiled. 

If in institutions but few should be put in the same ward, 
allowing plenty of air space to each infant. 



266 THE DISEASES OF CHILDREN 

CHEONIC ENTEROCOLITIS. 

Acute enterocolitis jfrequentlj ends in the chronic form. The 
acute symptoms subside, or perhaps the child shows a decided 
improvement, it is fed indiscretelj, and a second attack follows, 
which lapses into the chronic form. It is found in hospital 
cases of acute form which have improved and been allowed to 
return to unhygienic homes and bid food, with the chronic con- 
dition following. 

It may be seen at any age of childhood, an inflammation of 
the colon alone being more frequent, however, in older children. 

Pathology. There is usually a catarrhal inflammation of the 
mucous membrane of the colon, and the last 10 or 12 inches of 
the ileum. The inflammatory condition extends into the tubular 
glands and many of these are destroyed by pressure. There may 
rarely be an ulceration of the mucous membrane. The mesen- 
teric glands are enlarged. 

The most frequent complication in this form of trouble is a 
pneumonia, hence we find the lungs involved to various degrees, 
from a hypostatic condition to frank consolidations here and 
there through the lung, of the broncho type. 

Symptoms. The chief general symptom is a more or less 
rapid and progressive loss of weight, with abnormal evacuations 
numbering 6 to 10 in the 24 hours, or there may be twice as 
many. The stools are abnormal in color, content and consistency. 
They may be mushy and be composed mostly of a greenish 
mucus, or they may lose all color and be light and of pus char- 
acter. They may or may not contain blood, usually do if there is 
much straining. The color varies from a yellow to a brown, with 
all shades of green. If on milk or a general diet, curds and 
undigested food are present. 

The child quickly develops into that condition known as 
athrepsia or malnutrition, it emaciates quickly, its abdomen is 
distended, it is restless, fretful and cries a good deal, the fon- 



DISEASES OF THE DIGESTIVE SYSTEM 267 

tanelle is depressed, skin wrinkled, and it soon develops the old- 
man f acies, with tightly-drawn skin over the face. It lies upon 
its back or side with legs drawn up, the skin of the legs and 
arms is in folds, and there is no subcutaneous fat. The tempera- 
ture is below normal, and may reach but 95° F. in the rectum- 
Owing to the many discharges the skin of the buttocks may show 
an intertrigo, or at least a severe redness. Food will be gener- 
ally taken with greediness. The pulse is weak, the feet and 
hands cold. Occasionally, shortly before death, the feet and 
hands may be quite swollen. 

Diagnosis. The chief trouble to be differentiated is from 
tuberculosis, and in the absence of marked intestinal disturb- 
ance this may be difficult. In those cases which have a distinct 
tubercular family history, and in certain hospital cases it may 
be more puzzling. It probably cannot be positively determined 
without the use of tuberculin which is one of the diagnostic 
methods advised. When there is distinct involvement of the 
chest the diagnosis of tuberculosis is easier. 

Prognosis. This is universally bad. . While some cases may 
show an improvement even after several weeks of an apparently 
hopeless condition, the majority succumb. The prognosis is 
influenced by the age, surroundings, intelligence of mother or 
nurse, and feeding. The prognosis in children under one year 
of age is very grave. 

Treatment. 1. Hygienic. Fresh air and a change of 
climate, if possible, is of prime importance. If thoroughly pro- 
tected from exposure, the child should be out of doors almost 
continuously. Regular baths should be given, but without 
exposure. As described in the previous section the napkins 
should be carefully washed, and the child changed promptly 
when one is soiled. An abdominal binder should be worn in 
addition to the shirt. The binder in the form of the sleeveless 
shirt, made with shoulder pieces and tapes in front and back 
to pin to the napkin, is best. Stockings should always be worn 
and flannel skirt also. 



268 THE DISEASES OE CHILDREN 

2. Dietetic. In no other condition are precise instructions in 
regard to feeding so necessary. Written directions as to choice, 
mode of preparation, time, temperature and quantity of the food 
should be given the mother. The diet should be concentrated, 
leaving little residue. The digestive capacity for carbohydrates, 
fat and proteid is much enfeebled, and food within reach of the 
digestive capacity should be given. Fat-free whey; animal 
broths with fat removed ; dextrinized cereals ; predigested milk, 
when it can be borne, are the foods which can be tried. If one 
seems to cause a recurrence of the condition it is discontinued. 
Regularity of feeding is most important, not of tener than every 
two hours, and food given in 2 or 3 ounces at a feeding. Over 
feeding is greatly to be feared. If the child shows an inaprove- 
ment eggs can be added to the list, peptonized milk, lactone 
buttermilk, scraped beef, etc. A gain in weight, or if it stops 
losing with coincident improvement in the stools, is an assurance 
the child is improving. 

3. Medicinal, Castor oil at the onset and repeated occasion- 
ally is a valuable agent, 1 or 2 teaspoonfuls to an infant of one 
year. If not retained calomel in 1 grain dose should be given. 

The same directions as to the administration of opium in 
the acute form obtains in the chronic. It should not be com- 
bined with any other prescription. Dover's powder, in ^ to :^ 
grain doses, or paregoric, 10 or 15 drops, are the best prepara- 
tions. Bismuth is a valuable agent and can be given plain or 
in combination with tannalbin, if an astringent is needed, and 
salol, if there is much fermentation and odor present. Astring- 
ent injections should be given when there is much mucus, other- 
wise a colon irrigation of normal salt solution, under the same 
general rules as mentioned before. 

Stimulants should not be given unless there is a decided indi- 
cation for their use. Cod liver oil, internally, is of great service 
in convalescence when tolerated by the stomach, and frequently 
it can be taken when no other fats can be borne. 



DISEASES OP THE DIGESTIVE SYSTEM 269 

CONSTIPATIOI^. 

Constipation is more or less a relative term, but it exists when 
the bowel movements occur less frequently than is ordinary; 
when it is accomplished with difficulty, when the fecal matter 
is reduced in quantity, and is drier than normal. This is a 
common affection in children. 

Etiology. The chief cause of constipation in infancy is the 
conformation of the colon, especially the sigmoid flexure. Owing 
to the shallow infantile pelvis and the relatively long mesentery 
of the sigmoid, this portion of the large bowel is freely movable, 
often found beyond the middle line of the abdomen. During 
the first few months after birth the descending colon grows at 
the expense of the sigmoid and the apparently superfluous sig- 
moid is shortened. Because of this freely movable length of 
colon just above the rectum, it acts as a storehouse for fecal 
accumulations and is difficult to be emptied. Its contents move 
slowly and absorption takes place readily, causing increased 
dryness of fecal mass. Added to this is the distension which 
comes from fermentation, rendering movement less likely to 
occur. 

Constipation beginning soon after birth, especially when asso- 
ciated with vomiting should cause pyloric stenosis to be sus- 
pected. The fear of pain caused by a fissure may be a volun- 
tary cause of constipation. 

Late in childhood after typhoid fever, or an attack of appendi- 
citis, constipation is probably due to bands of adhesions acting 
as a mechanical cause of constipation. 

Dietetic causes of constipation should be carefully consid- 
ered. A deficiency in fat, in both breast and modified milk, 
with a relatively large proteid percentage is a cause. Too long 
continuance of a milk diet in late childhood and the absence of 
mixed food, carbohydrates, etc., may also act as a cause. Too 
little water in both the artificially and the breast fed ; prolonged 
use of a Pasteurized or sterilized milk may act as causes. 



270 • THE DISEASES OF CHILDREN 

Loss of muscular tone, such as follows the acute exanthemata, 
typhoid fever, or as is found in rickets and athrepsia, is a fre- 
quent cause. Failure to begin with regular habits and encour- 
agement to have daily evacuations at a regular time will cause 
constipation. It often follows an attack of acute enterocolitis, 
due sometimes to the too-prolonged use of astringent drugs in 
the treatment of the acute condition. The use of soothing syr- 
ups, all of which contain opium, for the cure or alleviation of 
colic is a potent factor in the development of chronic con- 
stipation. 

Symptoms. A normal number of evacuations is a purely rel- 
ative term, for what is normal to one baby is not to another. 
One child may be entirely normal with one evacuation and 
another may have two natural daily movements and be uncom- 
fortable without that number. 

The infant will normally have from two to four soft move- 
ments; later from the fourth to the sixth month they become 
less frequent, perhaps only two a day, and during the latter 
half of the first year the constipation usually begins. It will 
have one natural action a day, or it must be assisted to have 
that. Unless it has the one action a day and this is firm and 
hard, it is constipated. 

When a child has not had a movement for one or two days 
it may or may not present symptoms. It is, however, apt to be 
fretful and cross, there may be colic, nearly always flatulency, 
with distension of the bowels. 

Occasionally a case may be seen which has passed several 
large, firm, hard movements which have so stretched the sphinc- 
ter muscle as to cause the mucous membrane to tear. This does 
not heal, and a fissure of the anus results. Because of the pain 
caused by a movement when a fissure is present the child volun- 
tarily suppresses an action of the bowels and will not sit upon 
the chair or vessel. The pressure of the accumulated fecal 
masses in the rectum causes a passive congestion of the hemor- 
rhoidal plexus of veins and hemorrhoids result. A prolapsus 



DISEASES OF THE DIGESTIVE SYSTEM 271 

of the mucous membraiie may also occur as a result of the strain- 
ing. In some cases as a result of acute constipation, especially 
when previously regular actions have obtained, there may be 
vomiting with a slight rise of temperature of 2° or 3° F. They 
are restless, cross and peevish, have little appetite and sleep 
poorly. 

Prognosis. This is variable, depending upon the cause, age 
of child, duration, presence of complications, etc. Usually, how- 
ever, it is fairly good and by faithfulness in carrying out direc- 
tions will good results be had. 

Treatment. The chief indication is regularity in obtaining 
evacuations from the bowels. As early as six months the child 
must be taught to use the chair or vessel. It should not be 
allowed to sit too long upon these, because of the tendency to 
development of hemorrhoids. If there is no inclination in 15 
minutes to strain and assist the movement, a glycerine, pencil 
suppository or small amount, 8 or 10 ounces, of water thrown 
into the rectum from a fountain syringe, held about 3 feet 
above the child should be used. In using the syringe it is well 
to attach a soft-rubber catheter to the hard-rubber syringe tip 
in order to avoid injury to the rectum in its introduction. This 
will cause the child to strain to expel the suppository or water, 
and an evacuation results. 

Endeavor to locate the cause of the trouble. If it is dietetic, 
as indicated in the description of the etiology, correct this. If 
the mother's milk shows by an examination an excess of proteids, 
have her eat less meat, take more exercise and drink more water. 
If the child is on modified milk increase the fat content in the 
prescription, or if the age will permit, begin the varied diet 
and increase the amount of water taken. The average child, 
whether breast or artificially fed, is given too little water. 

The use of dextrinized gruels is of service as a diluent when 
modified milk is given, especially an oatmeal water or one of the 
flours made by the Cereo Company, Tappan, IST. Y. 

Abdominal massage is of great benefit, beginning the rub- 



272 THE DISEASES OF CHILDREN 

bing in the right iliac fossa, extending from this point over the 
course of the colon. This should be done with the child upon 
its back upon' a firm mattress. 

In the athreptic or marasmic infants, especially, and to others 
also, the administration of orange juice is of great assistance in 
this condition. The juice of half an orange can be given twice 
a day, not too close to a milk feeding. 

In children after the second year good results are obtained 
from giving mufiins or biscuits made from whole wheat flour, 
plain or mixed with bran. Cooked fruits are of value also, as 
stewed prunes and apples. Spinach and asparagus can be given 
older children to advantage. 

Medicinal. Medicine should not be resorted to until all other 
means of treatment have been exhausted. Of all the remedies 
suggested for constipation cascara sagrada is one of the most 
serviceable. It can be disguised by aromatics without its effi- 
ciency being destroyed. Almost any of the aromatic prepara- 
tions can be used to advantage. It acts as a tonic to the intes- 
tinal musculature, and from the maximum dose (20 to 60 drops), 
if used in connection with dietetic and other measures, can be 
reduced in a short time to the minimum dose (10 drops), and 
then discontinued. 

An occasional dose of calomel is of benefit, especially when 
the actions are very light in color. Rhubarb and soda can often 
be used to advantage as follows: 

IJ Pv. rhei 3iss 

Sodii bicarbonat 5i 

Syr. tolutan 5 i 

Aquae destillatae q.s.ad 5 iii 
M. ft. Sol. (Shake.) 
Sig. One teaspoonful once or twice a day. 

Syrup of tamarinds is of benefit used as cascara, 1 or 2 tea- 
spoonfuls at a dose, at bedtime, usually but one being required. 

Sodium phosphate, plain or effervescent, taken in the morn- 
ing before breakfast, well diluted, in certain cases is of benefit. 



DISEASES OP THE DIGESTIVE SYSTEM 273 

Two to five grain doses of carbonate of magnesia may be 
effective. 

In cases in which there is an impaction of the rectum and sig- 
moid an injection of first, a stimulating enema containing a 
half ounce of glycerine and of Rochelle salts can be used. If 
this is not successful, an emulsion of 6 ounces of fresh ox gall in 
1 pint of warm water may be effectual, of the injection of 6 
ounces of molasses and enough milk to make a pint may be 
tried. 

Phenolphthalein, in :J to 1 grain doses, may prove efficacious 
if other remedies fail. 

COLIC. 

Special consideration of this symptom is made necessary be- 
cause of the frequency with which it is encountered in infancy. 
It must be borne in mind, however, that the average mother 
or nurse attributes every crying spell an infant has to the colic, 
and a popular belief among the laity is that every child is likely 
to have colic until it is three months old. 

\Vhen a history is given of crying, with a tense abdomen and 
audible rumbling of gas in the intestine and the frequent eructa- 
tion of gas from the stomach, the condition is probably one of 
colic, but the frequency with which serious intraabdominal con- 
ditions may develop with colicky pains in the abdomen as the 
chief symptom, makes it necessary for careful consideration to 
be given each case in which abdominal pain is a feature. 

The colic which occurs in both breast- and artificially-fed 
infants is due to a fermentation in the stomach and intestines 
of the food ingested and the rapid accumulation of gas, the pain 
being caused by its passing rapidly from the stomach or through 
a knuckle of gut. It may also be due to a spasmodic condition 
of the intestine, produced by an undigested mass of food acting 
as an irritant as it passes through the bowel. In the artificially 
fed a too large carbohydrate content or the use of undextrinized 
cereal diluent may be the cause of the rapid fermentation. 



2?4 THE DISEASES OF CHILDREN 

A breast-fed child may nurse too quickly from a very full 
breast and swallow some air with the milk. It may stop in the 
midst of a nursing, throw off the gas, and resume the nursing. 
If held for a moment on the shoulder, with its abdomen being 
pressed upon, this eructation is facilitated. 

If the rubber nipple through which an artificial feeding is 
taken allows the milk to flow too freely, this same condition 
may obtain, or if the milk is taken too cold the tendency to 
gas formation is increased. Too frequent feeding is also a cause, 
the effect being an indigestion with fermentation. 

Symptoms. The chief symptom of colic is pain in the ab- 
domen, which causes the child to cry out, the abdomen is tense, 
and with the hand on the abdomen the gas can be felt as it moves 
in the intestines. The weight of the hand may sometimes give 
relief. The symptoms develop shortly after a feeding or, as 
already stated, may come while nursing, either from the breast 
or bottle, due to swallowing air with the milk. 

The child is restless and fretful, its feet and hands are cold, 
and it cannot be pacified in any position. It may fall asleep 
in the midst of its crying and waken with a start to resume. 

It is not uncommon, especially in the artificially fed, when 
the carbohydrate content of the milk is responsible for the gas 
formation, for the symptoms to develop several hours after a 
feeding, and the child may remain awake most of the night. 

Relief comes almost immediately after the gas is passed and 
the child falls into a restful sleep. 

Diagnosis. This must be made from appendicitis^ intussus- 
ception and acute middle-ear inflammation. 

In appendicitis there is an area of tenderness and localized 
rigidity. In colic the weight of the hand often affords relief, 
and the whole abdomen is rigid. 

In intussusception a tumor is apt to develop early, which is 
associated with acute constipation and bloody discharges. 
Bloody, mucous movements may be present in the colic which 
is present in acute gastroenteritis, but in the ordinary form of 
colic here described these stools are not seen. 



DISEASES OF THE DIGESTIVE SYSTEM 



275 



In the acute middle-ear inflammations the child puts its hand 
to the affected side or picks at the ear, and the character of the 
cry is different, it being more shrill and piercing than the cry 
from colicky pains. 

Treatment. Prevention. Care must be exercised as to the 
feeding of the child, reg-ularity, quantity, frequency, and in the 
artificially fed the food prescriptions should be carefully con- 










' ""i,***— * ^y~, 



FIG. 38. MUCOSA NORMAL COLON. X 300. 



sidered. If the child is newly put upon artificial food the first 
food prescription must be weaker than is necessary for the 
child's needs, and gradually increased until it gains in weight, 
in order that its digestion be not upset in the beginning. 

If on the breast, the breast milk should be clinically exam- 
ined by the Holt milk set, and any ingredient found at fault 
corrected, as indicated in a previous chapter. 

During the attack, thoce remedies are indicated which will 



276 THE DISEASES OF CHILDREN 

assist in the dislodgement of the gas. If the gas seems high 
up the administration of peppermint water, half teaspoonful in 
water, will assist the child in belching. 

The elixir of catnep and fennel in 10 or 15 drop doses is a 
serviceable remedy. Hot applications to the abdomen, the weight 
of the hand on the abdomen, letting the child lie upon a hot- 
water bag on a pillow, face down, holding it over the shoulder, 
causing pressure on the abdomen, are means which are of service 
in obtaining comfort. 

A warm enema, given through a catheter introduced more 
than half its length, containing a few drops of turpentine, will 
dislodge gas low down in the intestine and often produce com- 
plete relief. 

Soothing syrups should never be given as they all contain 
opium. Opium should not be given under any conditions as 
a routine, in fact, only as a last resort. If it is decided that 
opium is imperatively needed, paregoric is the best form, in 15 
or 20 drop doses, well diluted. The bromides are safe, and can 
be used if the child is very restless and cannot be quieted or get 
to sleep. 



Synonyms. Congenital idiopathic dilatation of the colon; 
Hirschprung's disease; giant colon; Mya's disease; mega colon. 

Etiology. This is a congenital condition. Those cases de- 
scribed in adult life (pseudomega colon) are believed to be 
delayed development of the congenital type or another condi- 
tion entirely, due to aggravated constipation. 

A number of theories have been advanced as to the etiology 
of this condition, none of which are convincing. The following 
have been suggested as causes: A neuropathic dilatation and 

* I am indebted to the excellent article of Dr. J. M. Finney, upon this subject 
in Surgery, Gynecology and Obstetrics, June, 1908, for much of the data of 
this chapter. 



DISEASES OF THE DIGESTIVE SYSTEM 



277 




ft Mr^^ -rm -■'^«^^^-'- 






*#"";t^ 



c^/' 










^.,-^*' ^. 







•- v^,n 




_r.^^ 


L-cr ii 






-C'jlari.b 

mucosae 


-£. 


■bnlu- 


osa , . 



FIG. 39. MUCOSA GIANT COLON. X 370. 



278 THE DISEASES OF CHILDREN 

hypertrophy; increased length of the colon; a valve formation 
in the intestine; spastic contraction of the sphincter ani; ab- 
normally long mesentery of the colon; chronic colitis, etc., etc. 
Boys seem more often affected. 

Pathology. The process in the majority of cases is limited to 
the sigmoid flexure. The diameter of the dilated portion may 
reach 6 or 8 inches, and it fills most of the cavity. The walls 
show dilatation and hypertrophy. The mesocolon is thickened 
and of irregular lengths. The blood vessels and lymphatics are 
much dilated. The mucous- membrane is thickened, congested 
and occasionally ulcerated. 




FIG. 40.* 

Microscopically the mucous membrane shows chronic inflam- 
mation. The circular muscular layer is enormously thickened, 
and the serous coat thickened with enlarged lymphatics and 
blood vessels. 

Symptoms. Enlargement of the abdomen, the most prominent 
symptom, associated with obstinate constipation, is present early 
in life. The large abdomen may be noticed at birth, but the 
child may be several months old, perhaps several years before 
the condition becomes very marked. The abdomen is then enor- 

*Figs. 38, 39, 40, and 41 reproduced through the courtesy of Dr. J. M. T. 
Finney, Baltimore, Md. from Surgery, Gynecology and Obstetrics. 



DISEASES OF THE DIGESTIVE SYSTEM 



279 



mous, the distension of the colon being due to gas and feces. 
History of a long period between evacuations of the bowels may 
be obtained, one case reported as three months. 

The skin is harsh and dry, complexion pasty, abdominal wall 
thin, through which peristaltic waves can be seen ; the veins of 
the skin are distended. Tympanites is quite general over the 
abdomen, the liver dulness decreased. 




€ 





FIG. 41. COXGEXITAL IDIOPATHIC DILATATION OF THE COLON. 



The movements from the bowel are apt to be dry or putty 
like, dark in color and offensive. 

Dyspnea may, late in the trouble, be quite marked, and 
bronchitis and pneumonia may be present. Atelectasis may 
be found in the lower portion of the lung. The pulse may be 
irregular. A cone-shaped dilatation of the bladder has been 
noted. The course of these cases is essentially chronic. There 
is an apathetic condition. 



280 THE DISEASES OF CHILDREN 

Diagnosis. Meteor ism and cliroiiic obstipation are the two 
symptoms practically always present. It must be diagnosed 
from tubercular peritonitis, volvulus, carcinoma of the intestine. 

Prognosis. While not fatal directly, the complications present 
may bring about death. Pulmonary heart and digestive dis- 
turbances may result fatally. 

Treatment. This is either surgical or medical. Surgically, 
the following procedures have been suggested : Puncture of the 
intestine (under no conditions to be done) ; colotomy, with 
evacuation of the contents and closure ; colostomy ; colopexy ; 
enteroanastomosis ; resection of affected portion and entero- 
anastomosis. 

Medically, the following measures have been suggested: 
Cathartics, enemata, massage, electricity, tonics, exercise, diet, 
etc. The mortality rate is given as follows: ''Surgical treat- 
ment has a mortality rate two-thirds that obtained by medical 
measures, and a recovery rate almost three times as great." 



CHAPTER XIII. 

Ils^TESTINAL PaEASITES. 

Intestinal parasites are comparatively infrequent, yet it is a 
common belief among the laity that every child which picks 
its nose or grits its teeth at night is affected with them. Because 
of this deep-rooted belief the subject is of considerable impor- 
tance. Among the facts elicited in regard to the child's history 
is, that it has been given some 'Svorm medicine" beforQ the 
physician has been consulted. 

Intestinal parasites are not seen in very young infants, but 
are found in children after a mixed diet is given, or after it 
crawls around on the floor, putting things in its mouth picked 
up from the floor. 

Varieties. The following intestinal parasites are found in 
children : The pin-worm oxyuris vermicularis, whose habitat is 
chiefly the sigmoid and rectum; the round worm, ascaris lum,- 
hricoides, found chiefly in the small intestine, and often in the 
stomach; the two species of tape-worm, the tenia solium, the 
pork worm and the tenia medio canellata, the beef worm; and 
the hook worm, the anhylostomum duodenale or uncinaria duo- 
denalisj as the name implies, found chiefly in the duodenum. 

OXYURIS VEEMICULAEIS. 

Synonyms. Pin-wonn; threadworm ; seativorm. 

Description. The habitat of this worm is chiefly in the sig- 
moid and rectum, the female worm, however, being found near 
the cecum. The worms and ova are passed in large numbers, in 
the feces and when entangled in masses can be easily seen. In 
girls the vagina may become infected from the discharges. They 
are very small in diameter, the female the longer, about 10 or 

281 



282 THE DISEASES OF CHILDREN 

12 ram. in length, the male 5 mm. The ova are quite small, 
oval in shape, .05 by .02 mm. in dimension. 

The mode of infection is by means of infected fingers, toys, 
fruit with the ova, these being carried to the cecum in the food 
and fecal contents of the stomach and intestine and there 
develop. 

Symptoms. The chief symptom is the intense itching of the 
anus, produced by the worms in the rectum. The child is very 
restless and is constantly scratching about the buttocks. A ca- 
tarrhal condition of the rectum may ensue. If they migrate 
into the vagina a vulvovaginitis results. Incontinence of urine 
may occur from the irritation of the bladder. In males an irri- 
tation of prepuce may result with swelling and pain on voiding. 
The skin about the anus and buttocks shows evidence of 
scratching. 

Diag'nosis. The anus and stools should be inspected in every 
case of pruritus, and if carefully done the worm will often be 
found. An enema should be given and the water returned care- 
fully examined. In every case of masturbation the presence of 
threadworms should be suspected. 

I had under observation a child whom I had previously seen 
in two severe attacks of enterocolitis, with large quantities of 
mucus passed for a long period of time. Upon the first appear- 
ance of mucus in the movements after this, I was notified. In- 
spection of what was thought to be mucus in a movement proved 
to be a mass of threadworms. The diagnosis was verified by 
microscopic examination. In this case the worms had not been 
present long enough to cause any symptoms. 

Treatment. The chief reliance in the treatment of these cases 
must be had in the use of injections into the colon through a 
long colon tube, as the habitat of the worm is below the cecum. 
The treatment must be thorough or the results will be corre- 
spondingly poor. First a preliminary dose of ol. ricini, 3ii, 
should be given, and this followed by a high cleansing, saline 
enema, of not less than 3 pints. After this solution has been 



INTESTINAL PARASITES 283 

allowed to pass tliroiigli the tube and with the child on the vessel, 
the tube is reinserted and an injection of 1 ounce of the infusion 
of quassia and 15 ounces of the normal salt solution given high, 
the tube quickly withdrawn, the nates compressed and the child 
kept quiet so this injection will be retained for at least an hour, 
if possible. This treatment is repeated each night for a week, 
at the end of which time a careful examination should be made 
of the stools, microscopically for the presence of ova. 

It should be remembered also that the ova become attached 
to the skin about the anus, and when scratching the fingers of 
the child can become infected, and they in turn carry the ova 
to the mouth, and a reinfection of the child take place. Hence, 
extra precautions should be taken in cleansing the nates after 
evacuations, and the constant application of a 10 per cent boracic 
acid ointment about the anus and skin surrounding. Care must 
be taken also of the napkins, night clothes and bed clothes, boil- 
ing after each removal. 

Anthelmintics may be used in connection with this treatment 
the most effective being santonin. 

ASCARIS LUMBPaCOIDES. ROUND WORM. 

Description. As indicated by its common name, this worm 
is round, being usually from 1 to 12 inches long, and tapering 
at both ends to a point. This worm is perhaps the one most 
frequently seen in children. The female is nearly twice as long 
as the male, the head having the projections, and provided with 
fine suckers. The tail of the male is turned upward. The ova 
are round, brownish in color, slightly larger than the ova of the 
threadworm. 

There may be only one worm present, but usually there are 
several. I have had one case in which two were vomited and 
88 passed per rectum. 

They may be found at any point tributary to the intestine; 
in the stomach, from which it is usually vomited, at any point 
in either large or small intestine, in the appendix and the gall 



284 THE DISEASEvS OF CHlLDKEN 

duct and bladder. Tliej may coil themselves together and form 
a mass of sufficient size to cause an intestinal obstruction. 

Symptoms. Large numbers of the worms may be present and 
cause no symptoms. The child mentioned which passed 88 was 
ill with malaria with high fever, worms were not suspected until 
the first one was vomited. The fever acting as an anthelmintic 
on the others as they passed from the bowel soon after. 

The vague symptoms referred to above may be present, but 
they have no significance as a diagnostic aid at all, being caused 
entirely by other pathologic conditions. The first symptom is 
the presence of the worm. The symptoms believed to be com- 
mon by the laity are restlessness at night, flatulency, picking at 
the nose, grinding the teeth, headache and convulsions. 

Diagnosis. As intimated, the only reliable diagnostic sign 
is the presence of the worm, either vomited or passed per rectum. 
In this event examination of the feces, microscopically, will re- 
veal the ova in large numbers. 

Treatment. One of the most reliable vermifuges is santonin. 
It may be given in connection with calomel. 

I^ Santonin 

Hydrargiri chloridi mitis aa gr. iii 
Triturate thoroughly. Ft. Cht. No. vi 

These are best given in the morning before breakfast, the child 
having had a very light supper the evening previous. This 
should be followed by a dose of castor oil (^ss) in four hours. 
On the second day following, the stools should be examined for 
the presence of ova. Toxic effects are sometimes obtained from 
santonin, hence it should always be taken with calomel. 

TENIA. TAPE- WORM. 

Description. The life history of the tenia is the ova, the 
larva and the mature worm. The ova are passed from a segment 
of the mature worm, which is found only in man and out with 
the feces. The egg then passes to the alimentary tract of an 
animal (the tenia solium in the hog, the tenia saginata in the 



INTESTINAL PARASITES 285 

beef). Tlie egg develops into the larva or embryo which pene- 
trates the intestinal wall by means of its hook-like processes, 
and becomes encysted in the muscle of the host, there to remain 
until set at liberty when eaten by man, where it develops in his 
intestine into the full-developed worm. 

The Tenia Saginata or Mediocanellata is from 15 to 30 feet 
long, and consists of segments, thick and yellowish-white in 
color, about an inch in length. They diminish in size toward the 
head, which has four suckers upon it. 

The Tenia Solium is shorter than the beef worm, measuring 
from 5 to 15 feet. The segments are shorter and narrower, and 
the head quite small. It is provided with four suckers, and a 
number of hooks. 

Symptoms. These are vague and indeterminate. The diag- 
nosis can in the majority of instances only be made by recog- 
nizing the segments in the feces. There may be symptoms of 
indigestion, restless sleej)ing at night, perhaps some colicky 
pains. Alternating constipation and diarrhea may be present, 
nausea and vomiting may also occur. However, an individual 
may be a host for years and never suspect the presence of the 
worm until a segTuent has passed. 

Treatment. Before treatment is begam careful instructions 
must be given that no passage from the bowel must be had except 
on a vessel, so it can be closely examined, and the head of the 
worm found, otherwise it could not be told whether the case 
was cured. 

The child is given a very light supper, and a dose of castor 
oil. Before breakfast the anthelmintic selected is administered, 
among which may be mentioned oleoresin of male fern ; pome- 
granate or its alkaloid, pelleterine ; kousso, turpentine and pump- 
kin seed. 

The oleoresin of male fern in 15 minim doses in a gelatin 
capsule if the child can swallow it, otherwise in emulsion every 
hour until four doses are taken. This is followed by a second 
dose of castor oil in three hours. 



286 THE DISEASES OF CHILDREN 

Pelleterine, while efficient, is too expensive for ordinary use. 
The following prescription is suggested by Townsend: 

I^ Oleoresin aspidii 3 i 

Tincture quillajae f.§ss 

Syr. aurantii dulcis f . § i 
Syr. aurantii q.s. ad. f . § vii 
M. et Sig. Take in two equal doses. 

Turpentine can be taken in an emulsion : 

I^ 01. terebinthinse 3iiss 

Aq. Menth. pip §ss 

Mucil tragacanth q.s. o ii 
M. ft. Emuls. 
Sig. One teaspoonful every three hours, to be followed by one or two doses 
of castor oil a day, in small amounts. 

ANKYLOSTOMUM DUODENAXE. 

Synonyms. Uncinaria duodenalis ; hook-worm disease. 

Description. The natural habitat of this worm is in the far 
south countries, but it occurs with fair frequency in this coun- 
try in the Southern States. 

In 1893 Blickhahn" reported a case in St. Louis, and in 1898 
Dabney reported a case in 'New Orleans, and Tebault another 
in the same city a year later. In 1902 Harris claimed that a 
number of cases of anemia in Georgia, Alabama and Florida 
were due not to malaria, as universally believed, but to un- 
cinariasis. 

Stiles states, 1, uncinariasis is pre-eminently a disease of 
sandy localities; 2, infection occurs chiefly in rural districts, 
but this is true simply because it is in such districts that less 
attention is given to the disposal of fecal matter and because 
more people in such localities are brought into contact with the 
soil; 3, whites are more often and more severely infected than 
negroes ; 4, infection, as a rule, takes place in more than one 
member of a family ; 5, children and women show a more severe. 

* Dock: Loc. cit. 



INTESTINAL PARASITES 287 

infection than men; G, in hot weather the symptoms of the 
disease are exaggerated. 

The embryos may exist for a month ontside the body and de- 
velop in a host. Pollntion of the soil from improper disposi- 
tion of the feces is the cause of its dissemination. It is seen 
in dirt eaters; and an infection can occur from uncooked food 
which is taken .by the child. The majority of these worms are 
found in the second portion of the small intestine^ and are pres- 
ent in large numbers as a rule. 

Symptoms. The symptoms in the host of the hook worm are 
believed to be due to a toxemia, chief of which is a profound 
anemia ; the subjects are thin and pale, with muddy complexions, 
the abdomens protrude and they have no endurance and tire 
easily. There is palpitation and dyspnea, headache and dizzi- 
ness are often present; they are dirt eaters and have perverted 
appetites ; have no ability to acquire knowledge or to work. 
They are listless, idle and shiftless. Disobedience, cunning, 
lying, stealing and other symptoms ordinarily attributed to 
hysteria are seen. The bowels are constipated and what is passed 
is often blood stained; the abdomen is often much distended. 
Hemoglobin is reduced out of proportion to the diminution in 
red cells. Hemic murmurs are heard. 

Diagnosis. The patient presents a rather typical picture, and 
the diagnosis can be confirmed by microscopic examination of 
the stools for the ova or the parasite can be seen by the eye. 
The ova are much larger than a red blood corpuscle, and have a 
colorless capsule. The parasite is half an inch long, size of 
a hat pin, and one end hooked back on itself. Stiles suggests 
the blotting-paper test for diagnosis, about an ounce of fresh 
feces are placed on a piece of white blotting paper and allowed 
to stand an hour. The feces are then removed and the color 
of the stain examined. Hi a large percentage of cases of uncin- 
ariasis the color is reddish-brown and reminds one of blood 
stain. This test is not considered reliable. 

A second test is a therapeutic one. Thymol is administered 
and the parasites are found in the stools. 



288 THE DISEASES OF CHILDREN 

Prognosis. This is good if the case has not progressed too 
far and the anemia too profound. 

Treatment. Snjder* recommends a preliminary dose of 
magnesium sulphate. Thymol, finely triturated, is given at 
4 p. m. and at 8 a. m. the following morning in dose of from 5 
to 20 grains, in capsules, on an empty stomach. This is re- 
peated at 10 o'clock and the dose of magnesium sulphate given 
at 12 o'clock. One or two, perhaps more, courses of thymol may 
be needed to control the condition. 

E'ourishing food and iron tonics are given too for the anemia, 
one of the best of the latter being diastiron in teaspoonful doses 
after meals, ^ux vomica is of service. The children shouid 
be removed from school. 



* Pediatrics, December, 1908. 



CHAPTEK XIV. 

Surgical Coxditioxs of the Ixtestixes. 

appendicitis. 

Definition. This is an inflammation of the appendix vermi- 
formis, and under this term, on account of the inability to differ- 
entiate cases clinically, is included all varieties of inflammation 
about the caput coli. 

Etiology. Typical appendicitis is rarely seen in early in- 
fancy, and but very rarely under ^ye years of age. At this age 
and until puberty the appendix being relatively longer than 
in the adult, and Avith a larger opening, is more liable to develop 
inflammatory conditions. This allows freer entrance of fecal 
matter which remains, and as a result of mild catarrhal inflam- 
mation forms the nucleus of an enterolith. The younger the 
child the more the attack dift'ers from one in an adult. 

The direct cause is of bacterial origin, the colon bacillus, the 
streptococcus and typhoid bacillus being most frequently re- 
sponsible, the inflammatory process being relighted violently 
in those cases in which an enterolith has formed in the appendix 
because of a pre-existing catarrhal condition which may in itself 
have been entirely unnoticed until the reinfection or recru- 
descence. 

In the child subject to that vague condition called lymphatism, 
in which there is a tendency to the enlargement of the lymph 
nodes generally, especially of the tonsils, appendicitis is much 
more liable to occur. The rapid progress of appendicitis in 
children has been ascribed to the abundance of lymphoid tissue 
existing in the child's appendix. It has been suggested that 
infection by the bacillus of la grippe or pneumonia is often 
responsible for the lighting up of an acute appendicitis. 

28918 



290 THE DISEASES OF CHILDREN 

Pathology. Four forms of appendicitis are clinically de- 
scribed: 1, cataii'hal; 2, ulcerative; 3, gangrenous; 4, sclerotic. 

1. Catarrhal. In this form the mucous membrane of the 
appendix is swollen, its lumen being almost if not entirely oblit- 
erated. The process is usually more severe around an enterolith 
if one be present. The mucous membrane exfoliates and the 
cavity is filled with broken-down cells and mucus. The swelling 
is usually more severe at the intestinal opening. After the 
subsidence of the catarrhal inflammation the mucous membrane 
never returns to a normal condition. 

2. Ulcerative. This is rarely a primary condition, the ulcer- 
ative being grafted on the catarrhal form. The ulcerative proc- 
ess may involve a few small areas or the entire mucous mem- 
brane of the appendix. In those cases of the ulcerative form 
in which there have been two or three attacks, without perfora- 
tion, and which finally subside and apparently get well, there 
remains a constricting band of mucous membrane at the site of 
the most violent ulceration. There may be one spot where the 
ulceration is more severe which may result in a perforation. 
The point where this occurs is near the tip, as a rule, though at 
the site of the enterolith the ulceration may be so severe as to 
result in a perforation. AVhen a perforation of all the coats 
of the appendix occurs, it may result in a general peritonitis 
or the formation of an abscess, walled off from the general 
cavity. 

3. Gangrenous. In this form the inflammation is so violent 
that a part or the entire appendix sloughs off, causing a general 
peritonitis or a localized abscess, as in the perforative or ulcera- 
tive form. 

4. Sclerotic. This results from a chronic inflammatory 
process involving a portion or the entire organ. As the inflam- 
mation subsides there is at its site a formation of new con- 
nective tissue which strangulates the normal structure, resulting 
in a replacement by fibrous tissue. 

In all forms but the last there may be a mild localized peri- 



SURGICAL CONDITIONS OF THE INTESTINES 291 

tonitis witli the formation of small, fine cobweb adhesions. In 
the latter these adhesions may be present as a result of the pre- 
existing acute process. In the perforative form, without a 
localizing inflammatory wall, a large quantity of pus rapidly 
forms in the cavity. This is usually thin and yellowish, and 
contains large flakes of plastic lymph or fibrin. 

Symptoms. 1. Catarrhal. In this form there is pain referred 
to the right side of the abdomen, more frequently in the right 
iliac region, but owing to the long mesoappendix in children it 
may be nearer the umbilicus, and not infrequently in the hypo- 
gastric region over the bladder, the epigastrium, or at any point 
from the liver to the iliac fossa. Xo dependence can be placed on 
the statement of the child regarding abdominal pain in appendi- 
citis. This is associated with tenderness over the site of the 
appendix, and quite early there develops a rigidity of the rectus 
muscle over the affected side, this guard being an involuntary 
manifestation. Rigidity must be difierentiated from voluntary 
spasm. It is less apt to be present in the catarrhal form to any 
great extent, but is always present in the other more severe 
forms. There is a slight rise of temperature to 100° or 101° F., 
with quickened pulse and respiration, and vomiting may be a 
prominent symptom. Diarrhea or constipation may be present, 
more often the former. Painful micturition may also be present. 
These symptoms may be so slight as to almost escape notice and 
go entirely unrecognized, being of short duration and not severe, 
and perhaps mistaken for an ordinary attack of colic. 

This was the case in an institution child, nine years old, under 
my observation, who had been ill for a few days with an ab- 
scess at the root of a tooth, relieved by extraction. The tempera- 
ture had been normal for two days when there was a rise to 
102f ° F. I was again called, and the closest questioning did not 
elicit any complaint or history which Avould aid in the diagnosis. 
1^0 complaint had been made to the infirmary nurse. A thorough 
examination was then made, the chest was negative, and on pal- 



292 THE DISEASES OF CHILDREN 

pation of the abdomen a distinct mass the size of an egg was 
found in the right iliac region, and an appendiceal abscess diag- 
nosed. This was concurred in by the surgeon, and the child 
operated upon within four hours. An abscess was found con- 
taining fully 3 ounces of fetid pus, and with great difficulty a 
perforated and gangrenous appendix was freed from the dense 
adhesions. 

This case is illustrative of the class, and also emphasizes 
that institution children cannot be taken as a guide as they are 
usually stoical and complain much less than children in private 
families. 

Attacks usually recur with comparative frequency, each one 
likely to be more severe than the former. AYlien there is a his- 
tory of frequent preceding attacks, careful palpation may reveal 
the congested and swollen appendix through the thin abdominal 
wall. 

2. The ulcerative form, as a rule, presents more acute and 
active symptoms, an exaggeration of those of the catarrhal type. 
The pain is more severe, the patient seems sicker from the 
onset, the temperature may reach 103° F., vomiting is recur- 
rent, great pain being caused by the retching ; the tenderness is 
located over the appendix, usually at a point midway between 
the umbilicus and the anterior superior spine, the so-called 
McBurney point. The bowels are more often constipated than 
loose, though a diarrhea may be present. 

This is the description of a classic case, but there are frequent 
anomalies encountered. Because of the atypical cases the diag- 
nosis, sometimes, is most difficult, and again practically no 
symptoms are present calling attention to the abdomen until 
a general perforative peritonitis has developed and the child 
is dangerously sick. 

3. In the perforative form with localization of the abscess 
there is an easily palpable tumor, rigidity of the right rectus 
muscle, high temperature, characteristic attitude, lying upon the 
back with legs drawn up ; hurried, shallow respiration, and rap- 



SURGICAL CONDITIONS OF THE INTESTINES 293 

idly forming and sometimes severe tympanites. The face has 
an anxions expression, and the pulse is small and rapid. There 
may be sweats. 

The blood count will show a marked leucocytosis and this 
may be a decided diagnostic aid. If there is a count of 18,000 
or more leucocytes the diagnosis is usually more certain. A 
steadily-increasing leucocytosis is a more typical picture and 
a worse sign than a single examination in which a large in- 
crease is found. 

Cabot states that mildest and severest cases show no leu- 
cocytosis. Catarrhal appendicitis is rarely accompanied by 
leucocytosis. A low count (8,000 to 11,000) means a mild 
case, a very severe case or an abscess thoroughly walled off. 
When a leucocytosis of 18,000 to 25,000 is maintained for a 
number of days, it usually means a large abscess pretty well 
walled off. Bloodgood considers that ''within the first 48 hours 
a leucocytosis of 18,000 should be considered an indication for 
operation, especially if there is a rising leucocyte count." A 
persistent low leucocyte count is generally a positive indication 
for operative interference when taken into account with the 
other clinical sigTis. 

The symptoms of the gangrenous form are practically those 
of the ulcerative type, except they are apt to be quicker in 
developing. 

4. Sclerotic appendices present most constant pain, nagging 
in character and are accompanied by more or less digestive dis- 
turbance. Palpation reveals tenderness and slight rigidity. 

Diagnosis. This, as a rule, is not very difficult, but has to 
be made from a pneumonia, pleurisy, especially of the lower 
portion, and of the diaphragmatic layer, intussusception and 
volvulus. 

The most frequent mistake in diagnosis would be in mis- 
taking an acute appendicitis of mild type for an acute indi- 
gestion or colic. 

In right-sided pneumonia the characteristic expiratory grunt 



294 THE DISEASES OF CHILDREN 

is present, dilatation of the alee nasi, redness of the cheek of the 
affected side, and the characteristic physical signs, as well as a 
much-quickened pulse and respiration in the typical ratio of 
pneumonia, and higher temperature. It must be borne in mind, 
however, that in some cases of central pneumonia there may be 
few of the typical pneumonia symptoms present. Cough may 
be wholly absent. Morse^" stated that ''the abdomen has been 
twice opened in children by w^ell-known Boston surgeons for 
appendicitis, Avhen the trouble was lobar pneumonia." 

Examination of the chest should be made in every case of 
suspected appendicitis in a child, and in cases of grave doubt, 
wait until developments clear up the diagnosis. 

In a diaphragmatic pleurisy there may be more difficulty in 
making a diagnosis as the physical signs of a pleurisy are 
masked, the pain is apt to be referred downw^ard, and there 
may be slight rigidity of the right rectus muscle. The restricted 
freedom of movement of the chest is one of the chief signs. 

In intussusception the early presence of the tumor, which is 
movable, the associated vomiting, of stercoraceous type if ob- 
struction is complete ; the passage of bloody mucus, and without 
much fever, is sufficient to make the diagnosis of this condition. 
The tumor of an intussusception may be felt by a rectal 
examination. 

Prognosis. Even if of a mild catarrhal type attacks are apt 
to be recurrent. Age is an important factor. The prognosis 
is graver the younger the child and the more severe the type 
encountered. In the acute perforative and gangrenous types it 
is especially bad and a guarded prognosis should be given in 
every case. 

Treatment. In no case of appendicitis should the pediatrist 
conduct the case without the advice of a surgeon who, in justice 
to all concerned, should be called early. The disease is essen- 
tially a surgical one, and in the majority of cases an operation 
is indicated. 

* American Gynecology and Pediatrics, vol. 13, p. 143, 1900. 



SUKGICAL CONDITIONS OF THE INTESTINES 295 

If appendicitis is even suspected, the child must be put to 
bed, put on a starvation diet for a few hours, and an ice bag 
applied to the abdomen. An enema should be given promptly. 
Opiates should not be given as they mask the symptoms and ren- 
der later and more positive diagnosis difficult. 

If the ulcerative type can be diagnosed, an operation should 
be performed early. Kelly gives the following reasons for the 
early operation, during the first 24 hours: "It is safest, the 
operation is more easily done, the patient is spared days of 
suffering; the liability to recurrent attacks and the risk of 
hernia are obviated.'^ 

Richardson^ states "that the appendix should be removed in 1, 
all severe cases seen early, unless there are contraindications to 
operation in other organs or in the patient's general condition ; 
2, in all severe cases which when first seen are at a standstill 
or are increasing in severity ; 3, in all cases in which the symp- 
toms are well marked and well localized; 4, in all severe cases 
unless they are unmistakably improving; 5, in those cases in 
which the disease is limited to the appendix itself, and it is 
presumably certain the abdomen can be closed without 
drainage." 

If more than 24 hours has elapsed since the initial symptoms 
the operation had perhaps best be postponed until later. 

The interval operation is indicated in recuiTent cases, the 
mortality in these being nil. 

The operation in a child is usually easier than in an adult. 
The muscles are thinner in the abdominal wall and anesthesia 
relaxation easier produced. The operation should always be 
quickly performed, as the time element in the production of 
the shock is very great. Because of the need of stimulation, 
ether is the best anesthetic to be used. Care in its administra- 
tion is more necessary than in adults. 

Because of the various locations of the appendix in the child, 
no special incision can be selected for all cases; it should be 

* Park's Sui^ery, 



296 THE DISEASES OF CHILDREN 

made long enough primarily in order not to be obliged to lose 
time bj enlarging it later. Some discretion is necessary in de- 
ciding whether to drain, to prolong the operation looking for 
the appendix in gangrenous cases, etc. 

Postoperative temperature is the rule for a day or two. To 
combat the thirst, saline enemas every four hours should be 
given in amounts which it is found the child will retain, and 
water by the mouth as soon as there is no nausea. Liquid nour- 
ishment is given early. 

Opium can be given for great pain and restlessness. Bromides 
may be used in the less severe cases. 

IKTUSSUSCEPTIOW. 

This condition is an obstruction of the bowel due to the slip- 
ping of one segment of the bowel into another. When one sees 
the large number of postmortem intussusceptions in one case, 
it is a wonder it is not more often encountered in the living. 
Frequently as much as 10 or 15 inches of the small gut will be 
found invaginated at the autopsy, there being often a number 
of these, and the invaginations are easily reduced. 

Pathology. The invagination is from above dowuAvard, in 
the direction of the fecal current. There are three layers of 
bowel at the tumor, the outer, invaginating, covering or re- 
ceiving layer is the intussuscipiens , the inner layer the intus- 
susceptum. The narrow, constricted end is the neck. The neck 
is very frequently the ileocecal valve, and several feet of the 
ileum may pass through the neck into the colon. 

Etiology. Two theories of the cause have been presented, the 
theory of spasm and of paralysis. 

Wallace* suggests that a portion of the bowel is damaged by 
some interference with its blood supply and bulges and may 
perforate, and that the intussusception is the result of nature's 
effort to reinforce the weak piece by splinting it between healthy 

* Journal American Medical Association, April 11, 1908. 



SURGICAL CONDITIONS OF THE INTESTINES 297 

layers of intestinal wall, and that instead of being the cause of 
the trouble the invagination supports the weakened intestine. 

It is more apt to occur during an attack of acute intestinal 
disorders when peristalsis is most active. The relatively long 
mesentery of the bowel in infancy and the thinness of the bowel 
wall has been given as a cause. It is rarely seen in early in- 
fancy, being most frequent from the sixth month to the second 
year, and quite rarely after this period. In a large percentage 
of cases the invagination occurs at the ileocecal valve, the small 
intestine slipping into the colon, the large intestine literally 
swallowing the small, though many occur in the small intestine. 
It occurs more often in boys, in the ratio of about two to one. 

Quite rarely the reverse of the above is seen, where the intus- 
susceptum will be a segment of bowel from below, telescoping 
into the intussuscipiens above. If much of the bowel is in- 
vaginated owing to the mesentery being attached, the tumor 
is curved on itself, because the mesentery attached to the bowel 
is pulled in after it. 

Owing to the constriction at the neck and engorgement of the 
intussusceptum, pathological changes occur quickly, but the ex- 
tent of these depend upon the length of time which the condition 
has existed. If it has existed for some time reduction may be 
impossible, both from the adhesions formed and the greater en- 
gorgement of the apex of the intussusceptum. Only one thing 
can occur, if enough time elapses, viz., sloughing of the intus- 
susceptum at its most constricted portion. Adhesions form be- 
tween the invaginated layers, and as inflammation of the peri- 
toneum progresses adhesions of coils of the bowels may occur 
externally. 

Symptoms. The onset is usually sudden, and if much of the 
bowel is invaginated and sudden constriction occurs, the onset 
may be associated with some shock. Pain is a prominent symp- 
tom, sudden and violent. The child cries out, draws up its 
legs and vomiiing shortly begins. Distension of the abdomen 
is soon noted and the child will soon pass blood and mucus 



298 THE DISEASES OF CHILDREN 

from the rectum. The first evacuation may be fecal, but it is 
soon followed by blood and mucus. This is one of the char- 
acteristic symptoms. There is usually no fever at the onset, in 
fact the temperature may be subnormal, and its elevation indi- 
cates beginning peritonitis, but the respirations and pulse, 
especially the latter, are accelerated. If obstruction is complete 
the vomiting may soon become stercoraceous in character, us- 
ually not occurring, however, until late. Later, as peritonitis 
develops there is a rise of several degrees in the temperature. 

The child has an anxious expression, in fact looks sick. The 
presence of a tumor in the abdomen is convincing proof of the 
condition. Through the thin abdominal wall of the child this 
can usually be found, unless the tympany has been too rapid in 
forming. As the intussusception is so often found at the ileo- 
cecal valve, the tumor is most often to be found on the right side 
of the abdomen between the right iliac region and the right 
hypochondrium. The tumor is doughy to the touch, is sausage- 
shaped and rounded. The child may be so sensitive as to make 
palpation of the abdomen impossible. In many cases the tumor 
or intussusceptum can be felt through the rectum, especially if 
the invagination is in the sigmoid. Hiccough may be present 
and is an unfavorable sign. 

The duration of the attack varies greatly. The attack may 
be so acute as to be fatal in 24 hours, unless the diagnosis is 
made early and the condition relieved. Other cases may run 
on for four or five days, and one unusual case has been reported 
by Snow* of Buffalo in which a seven-months'-old child suffered 
from an intussusception for 16 days, when a piece of gangrenous 
intestine 6 inches in length protruded from the rectum, was 
ligated and removed, recovery following. 

Diagnosis. The chief diagnostic points are the sudden onset, 
great pain, acute obstruction of the bowel, bloody-mucus evac- 
uations, the presence of the tumor in the abdomen, absence of 

* Carr: Practice of Pediatrics, 



SURGICAL CONDITIONS OF THE INTESTINES 299 

fever at the beginning, the continuous vomiting and the 
tympany. 

There is a train of symptoms not seen in any other condition, 
but even with the association of a few of them, an intussuscep- 
tion should be suspected, and in a child this suspicion becomes 
verified if a sausage tumor is felt in the belly or the invaginated 
gut palpated per rectum. 

Prognosis. This is necessarily grave, the mortality being 
over 60 per cent in a number of cases reported by different ob- 
servers. Prompt operative interference offers good results. 
Temporizing by trying this or that mechanical means of reduc- 
tion renders the prognosis less favorable, if operation is finally 
resorted to. Chronic cases, because of adhesions, render the 
operation very difficult. 

Spontaneous cures by sloughing off of the intussusceptum have 
been recorded but they are rare, and cases should never be 
neglected by waiting for this result. 

Treatment. The only safe and satisfactory method of treat- 
ment is surgical ; a laparotomy and. reduction of the intus- 
susception by slipping out the invaginated portion of the gut. 
The earlier this is done the more satisfactory the results. The 
longer the operation is delayed the more dangerous it becomes 
and the more difficult the reduction because of the adhesions 
formed between the layers of the gut. Eeduction may be impos- 
sible, rendering resection of the bowel imperative. This is nec- 
essarily a very serious operation in an infant. 

Owing to the tendency for the invagination to recur at the 
same site after reduction, the mesentery should be shortened at 
the time of operation. Chloroform should be the anesthetic of 
choice during operation. 

Palliative methods of treatment offer less than the operative, 
promising practically nothing. The ones recommended are the 
inflation of the bowel by gas, and the injection of water, the 
patient being inverted during both of these treatments. I do 
not think tliey should be used under any conditions. 



300 THE DISEASES OP CHILDREN 

The injection of air can be accomplished through a large 
catheter or rectal tube by a bicycle or automobile tire pump, 
great care and gentleness being exercised. If water is used it 
can be injected through the same catheter or tube, the fountain 
syringe being held 4 or 5 feet above the patient, and 3 or 4 
quarts of water used at an injection. The hand should be held 
upon the tumor during this treatment so that the reduction of 
the intussusception can be ascertained. 

If reduction is perchance accomplished, the child must not 
be fed for 8 or 10 hours, kept in a partly-inverted position, and 
under the influence of an opiate for at least two days. 



CHAPTER XV. 
General Diseases. 

typhoid fever. 

Synonym. Enteric fever. 

Definition. An acute, infectious, febrile disease due to the 
entrance into tlie body of the bacilhis of Eberth. 

Etiology. The disease is due to the bacillus of Eberth, which 
is taken in the body through the stomach, in food or drink, 
usually either water or milk. Infected dishes or spoons may con- 
vey the bacillus, or the hands contaminated by the discharges 
from the bowel or kidneys of a patient with typhoid may carry 
them to the mouth. 

In 638 epidemics of typhoid fever 17 per cent were due to 
contaminated milk, as reported in Milk in Its Relation to Pub- 
lic Health. This reports 138 epidemics traceable to a specific 
pollution of the milk. 

The number of cases of typhoid fever occurring in the camps 
during the Spanish- American War called attention to the fly 
as a disseminator of the contagion in a very practical and serious 
manner. Levy believes they can enter the body through dust. 

Age. The infrequency of typhoid in infancy is due to the 
number of breast-fed infants; when put on artificial food the 
chance of contagion is greater. I have seen one case of typhoid 
develop in a breast-fed infant six months old, who was weaned 
because of typhoid in the mother; the attack in the infant be- 
ginning in the third week of the mother's illness. 

Dividing the first 15 years into equal parts the far greater 
number of cases of typhoid occur during the last period, the 
least during the first, though it is not infrequent after the 
second year. 

301 



302 THE DISEASES OF CHILDREN 

In this section of the country, and along the valleys, it occurs 
more frequently during the late summer and fall months. A 
prevalence of typhoid is always expected following the first rains 
after a prolonged drouth where the water supply is not filtered 
or boiled. 

Bacteriology. Eberth first described the bacillus of typhoid 
fever in 1880. It is a small, short organism with rounded ends 
and very motile, with numerous flagelli, the latter being stained 
by Loeffler's method. It is both saprophytic and parasitic. They 
grow at room temperature, and are killed at 60° C. They are 
very hardy, cold does not affect them, and they live from 7 to 
10 weeks on articles of clothing or other objects. They grow 
readily and characteristically upon acid potato, bouillon and 
milk. 

They are thrown off from the body in the discharges from 
the bowel and in some cases in the urine, both of which may 
cause a dissemination of the disease. 

Pathology. The bacilli gain entrance to the body through the 
mouth, and because of their resistant nature are not harmed 
by the acid juices of the stomach, passing into the intestine, and 
find lodgement in the agminated glands or Pyer's patches. The 
bacilli propagate in these glands, and as a result there is an 
increase in the number of cells, the gland undergoing a regular 
pathologic change, swelling, necrosis, ulceration and cicatriza- 
tion. From the Pyer's patches the bacilli enter the lymphatic 
and general blood circulation, and are found early in the disease 
in the mesenteric glands, spleen and blood current, the kidneys 
and skin. 

Autopsy findings in the very young differ some from those 
in older children, in that the ulceration is not so great in in- 
fancy. The process in older children is similar to that in adults. 

There is decided enlargement and some softening of the mes- 
enteric lymph glands, and an enlargement of the spleen. The 
spleen can practically always be palpated in typhoid, as it is 
quite perceptibly softened and enlarged. 



GENERAL DISEASES 303 

Symptoms. My experience has been to find that, as a rule, 
typhoid fever in children is milder, of shorter duration and 
fewer complications occur than in adults. 

Period of Incubation. The onset is usually gradual, though 
it is not at all infrequent for the attack to be explosive in its 
onset, with vomiting and fever, the child being apparently en- 
tirely well previously. During the period of incubation it is 
apt to be droopy, not inclined to play or be amused; if old 
enough complains of headache and loss of appetite. There may 
be a slight rise of temperature at this time, but it is usually 
not taken until the child is believed to be sick. l!^ot infre- 
quently there seems to be an overwhelming of the nervous sys- 
tem by the toxins, the symptoms at first resembling meningitis. 

Period of Fever. The typical fever curve of the adult type of 
typhoid is not always seen in children, especially those cases 
of the explosive type or which begin with a chill. In these the 
temperature is high from the onset. The temperature may be 
found to rise gTadually, with morning remissions and evening 
rise, each day, both the morning and evening record, being 
higher than the previous day, until the second week, when the 
temperature rises to about the same line each afternoon, with 
a degree or two morning remission. The maximum evening 
temperature is usually not much over 104° F., though it may go 
higher. 

During the third week there is a gradual fall, the morning 
temperature not infrequently reaching normal by the eighteenth 
day. The division of these fever periods into weeks is an en- 
tirely arbitrary one, representing more the stages, the rise, the 
continuously high fever, and the drop by lysis, than division 
into the seven days constituting a week. 

Hyperpyrexia is infrequent. A sudden drop in the tempera- 
ture to normal or below is alarming, pointing usually to a hemor- 
rhage from a Pyer's patch. 

The pulse increases in frequency as the fever rises, but is us- 
ually faster than would be expected. As the temperature falls 
during the third week, the pulse is apt to be dicrotic. 



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GENERAL DISEASES 305 

The tongue does not show as marked change as in the adult. 
It is coated from the beginning but rarely is as dry as in adult 
typhoid. The coat becomes more marked in the center and the 
edges red. The mouth is dry and often ulcerated. 

The stomach in the beginning may be upset. Early vomiting 
is not infrequent, but later is exceptional. The towels are dis- 
tended after the first week. Tympanites is not marked until the 
second or third week. There may be diarrhea, but constipation 
is very often present. If diarrhea is present ^ ^pea-soup" dis- 
charges are the rule. It is very frequent that enemas must be 
given regularly to obtain evacuations. Nosebleed occurs less 
frequently in children. 

The eruption of the rose-colored spots appears early in the 
second week, and is seen in practically all cases. They are gen- 
erally on the skin of the abdomen, though they may be found 
on any part of the body. These spots are small, papular, slightly 
raised and disappear on pressure. I have never failed to find 
them when they were looked for carefully. 

Headache is not a prominent symptom after the first week, 
though restlessness may be a feature after this time. The head- 
ache at first is often very severe and suggestive of meningitis. 
Stupor and delirium are frequently seen in children, the latter 
being of the low, muttering type, with picking at the bed 
clothes or imaginary objects frequent. 

There is a reduction in the number of both the red and white 
blood cells, the reduction being much greater after a hemor- 
rhage. There is a coincident decrease in the hemoglobin. The 
Widal reaction is present early in the second week. This is a 
typical reaction, and is due to the production of a substance in 
the blood, which when added to a solution containing active 
typhoid bacilli causes them to cease moving and to form in 
clumps. The urine is diminished in quantity, and during the 
height of the fever high-colored and high specific gravity. The 
toxicity of the urine is increased. When the kidneys are in- 
vaded by the bacilli, an inflammatory process is set up, mani- 



306 THE DISEASES OF CHILDREN 

fested by albumen hyaline and granular casts. This is a 
complication and not seen in every case. 

The diazo reaction is present in a large percentage of cases, 
and somewhat earlier than the Widal test — probably as early 
as the last of the first week. 

In inflammatory conditions of the kidney due to the presence 
of the bacilli, the organisms can be found in the urine. 

The lymph nodes are enlarged and can be palpated in the 
neck, axilla and groin, though they do not reach the size of 
the nodes in the other infectious diseases. 

Complications. Hemorrhage is seen less often in children 
than adults. It occurs usually at the end of the second or begin- 
ning of the third week. I have observed hemorrhages but 
twice in my cases in children. A hemorrhage is very regularly 
followed by a drop in the temperature of from 3° to 5° F., a 
corresponding increase in the pulse rate and acute anemia and 
prostration. 

Perforation occurs more often in the hemorrhagic cases. Its 
occurrence is associated with sudden and acute pain, and prob- 
ably some rigidity of the abdomen, but there are no other de- 
cided symptoms which are always present. Peritonitis follows 
a perforation in a short time, shock is usually present, and a 
fatal termination prompt. In the only case which has come 
under my observation the following history presented : 

Boy, aged 13, irregular temperature for one week, continu- 
ously between 101° and 103° F. after the sixth day; first spots 
noted on the twelfth and thirteenth days. Active delirium from 
the seventeenth day, with great restlessness ; nosebleed on twen- 
ty-second day, with hemorrhage from the bowel on the twenty- 
third day, and a very large intestinal hemorrhage on the twenty- 
fourth day. Temperature chart from the twenty-third day until 
death is given. Twenty-sixth day the pulse was 130 and very 
weak; twenty-seventh, vomits nourishment; thirtieth day, 
rational at times and complains constantly of pain in his 
abdomen ; thirty-first day completely deaf ; death on the thirty- 



GENEKAL DISEASES 



307 



second day of his illness. Postmortem showed general peri- 
tonitis, fluid in pelvis, bowel covered with thick layers of plastic 
lymph; one perforation, punched out in appearance, one-fourth 
inch in diameter, about 10 inches from the cecum ; no adhesions 
about perforation. 

Bronchitis is a frequent complication and a bronchopneu- 
monia not uncommon. The occurrence of a rapid respiration. 




FIG. 43. TYPHOID fever; hemorrhage; perforation. 



slightly higher temperature and cough is sufficient to cause the 
respiratory organs to be suspected. The bronchopneumonia is 
hypostatic in character and occurs as a late complication, while 
bronchitis is seen earlier. 

Chorea may develop late in the attack or during convalescence. 
Reports of melancholia and mania have been made as compli- 
cations of typhoid fever. 

Otitis media, due to the direct infection of the middle ear 



308 THE DISEASES OF CHILDREN 

by the bacillus, occurs in a small percentage of cases. It is 
usually mild, and tends to recovery without complications. 

Aphasia is an infrequent complication, but a very striking 
one. The following case is illustrative: 

Lucile M., aged five and a half years, the only child of a 
young mother. She was spoiled and petted, and was taken 
rather suddenly ill the first week in January, 1906. Typhoid 
fever was early suspected by the attending physician, but the 
diagnosis was not confirmed until January 8, when the rose 
spots were first discovered. It was entirely impossible for the 
child to be controlled at the home of her parents, and she was 
removed to the residence of a relative of whom she was very 
fond. Every member of the family was ostracised, and the 
child put in the entire charge of a day and a night nurse. 

It is difficult to adequately convey the impression of the 
kind of patient we had to deal with in this little girl. She 
was willful, peevish, petulant, cross, defiant and extremely 
difficult to control. From the temperature chart exhibited it 
can be seen that the course of her attack was moderately severe. 
The maximum temperature was 105 °F., reached on the thir- 
teenth and fourteenth of January, the seventh and eighth days of 
her attack. The impression of the toxins on the central nervous 
system was quite profound, there being delirium, involuntary 
passages from both bowel and bladder, and muttering talk. On 
the seventeenth day there was difficulty in swallowing, but this 
was of only two or three days' duration. 

Three or four days after the temperature reached normal the 
child was noticed to mumble its words, where her speech pre- 
viously had been all right. She did not articulate plainly 
enough to be understood. She was asked if she wanted a drink 
of water and seemed frightened when she could not reply. From 
this time for three weeks she did not utter a sound. At the 
end of this time she was heard to make a sound ; in a few min- 
utes she mumbled unintelligible words, much as she had done 
at the beginning of the attack. For two or three days this 



GENERAL DISEASES 309 

mumbling continued and by the end of the week she was talking 
plainly. She did not have to be taught words or their meaning. 
As soon as she began to articulate she had no difficulty in the 
least in framing sentences. 

Her convalescence from this time was uneventful and rapid. 
During the next winter she attended school for the first time, 
however being kept out of her class on account of whooping- 
cough and measles for a good portion of the time, yet she was 
promoted to the next grade. 

Furunculosis is often observed in children. Inflammatory 
joint lesions occur during the latter part of the disease or during 
convalescence, and occasionally bony changes, abscess of the 
bones being the most frequent form of trouble. 

Diag^nosis. Diagnosis must be made chiefly from tuberculosis, 
malaria, gastrointestinal infection, pyelitis, meningitis, sepsis, 
appendicitis, ximong the chief diagnostic points may be men- 
tioned the fairly typical temperature, enlarged sixteen, rose-col- 
ored spots and the laboratory methods of diagnosis; Ehrlich's 
diazo reaction and the Widal test. The diazo reaction is ob- 
tained as follows: Two solutions are prepared, (1) a saturated 
solution of sulphanilic acid in 1000 cc. of water and 50 cc. 
hydrochloric acid; (2) a 0.5 per cent solution of sodium nitrite. 
To 10 cc. of the sulphanilic acid solution in a test tube are 
added 4 drops of the sodium nitrite solution and 10 cc. of the 
suspected urine. These are well shaken, and a layer of am- 
monia floated on the surface. A bright-red ring at the point of 
contact of the two solutions appears if the urine is from a 
typhoid case. A deep-red color should also appear in the fluid 
and the foam when the solution is well shaken. 

The Widal test* is made as follows : 

A drop of fresh or dried blood from the ear of the patient is 
diluted with 5, 10 and 25 or more times as much saline solution. 
A drop of fresh, virulent bouillon culture of typhoid bacilli 
is then added to each, thus forming dilutions of 1:10, 1:20 

* French: Practice of Medicine. 



310 THE DISEASES OF CHILDREN 

and 1:50, respectively. The specimens are immediately exam- 
ined under the microscope in the hanging drop. The typhoid 
culture should be from 18 to 24 hours old and made from a 
stock culture that is known to react readily to the serum test. 
It should be examined in the hanging drop before the serum 
has been added in order to see that it is free from clumping. 
If the bacilli are very numerous, the culture may be diluted 
with salt solution. The agglutination may occur immediately 
or after 10 or 15 minutes. The bacilli appear grouped together 
in irregular tufts of variable size and become motionless. The 
time at which the reaction becomes distinct in the different dilu- 
tions should be recorded. In the dilution of 1 : 10 an imme- 
diate agglutination generally takes place. It may occur in a 
dilution of 1:50, 1:100, or even higher. A specially devised 
agglutinometer for making the test without the use of living 
cultures or the microscope may be employed. 

The absence of this reaction throughout a disease may be 
regarded as positive evidence that typhoid fever is not present, 
since it has been found in 9Y.9 per cent of 48 9 Y cases collected 
by Brill. 

An agglutination of the typhoid bacillus has been obtained 
from the blood of patients suffering with malaria, typhus, mil- 
iary tuberculosis, cerebrospinal meningitis, and other acute in- 
fections, but rarely in a higher dilution than 1:5. A reaction 
obtained from a dilution of 1 : 30 is, therefore, a positive demon- 
stration of typhoid fever in nearly all cases, unless the patient 
has previously passed through the disease, for the blood often 
continues to agglutinate the bacilli for many years after re- 
covery. About half the cases do not give a positive reaction 
before the beginning of the second week, and about a third of 
the cases do not give a reaction before the early part of the 
third week. It may appear, on the other hand, as early as the 
fourth or fifth day. Rarely, it is first obtained in a relapse. 

Tuberculosis. There may be some difficulty in differentiatiixg 
this disease from typhoid, and the laboratory aids to diagnosis 



GENERAL DISEASES 311 

may have to be called upoii to clear it up. The occurrence of 
a previous pneumonia^ pertussis, prolonged bronchitis, emacia- 
tion, etc., is more common in tuberculosis. In tubercular men- 
ingitis the mental symptoms are prominent early and become 
gradually more profound, while in typhoid the meningeal symp- 
toms appear early. 

Malaria in the South may be mistaken for typhoid. The 
presence of the plasmodium in the blood and the response of the 
condition to quinine are diagnostic points of value. 

Gastrointestinal infection may present symptoms which are 
confusing. Usually the temperature curve is not so high or long 
and the intestinal symptoms are more marked. 

Pyelitis is very apt to be confused. In one of my cases of 
pyelitis, because of the inability to obtain a sample of urine for 
some days, typhoid was strongly suspected, but the diagnosis 
was cleared up as soon as a microscopic examination was made 
of the urine. 

Septic conditions, such as arise in Pott's disease of the spine 
with abscess formation, abscess of the liver, and other deep- 
seated abscesses may be confusing at first. 

Close observation and inspection of the abdomen should make 
the differentiation between appendicitis and typhoid easy. The 
rigidity of the abdomen and tumor with abscess formation is 
quite typical of appendicitis. 

Prognosis. In uncomplicated cases the prognosis is good. 
The younger the child the more grave the prognosis. Hemor- 
rhagic cases are more often fatal. Griffiths reports a mortality 
of 3 per cent, Abt. reports a mortality of 2.9 per cent. Perfora- 
tion is always fatal without operation. The course is milder 
in children and the duration shorter as a rule. 

Treatment. Prophylaxis. Proper care and disinfection of 
the evacuations and urine of typhoid fever patients would 
greatly lessen the number of cases which are annually seen. In 
the country, wells and cisterns should be carefully protected 
from sewerage and drainage from the house, and removed from 



312 THE DISEASES OF CHILDREN 

the outhouses and privies. In cities, unless the city water supply 
is filtered, all water which is given the children should be care- 
fully boiled. Only a certified milk should be used where it 
is obtainable. If a market milk is used the dairy from which 
it comes should be visited and the methods of the dairyman 
learned. Frequent inquiry should be made as to the presence 
of illness on this place, and if these conditions are unsatisfac- 
tory the milk should be sterilized before being used. 

If a case of typhoid occurs in a private family careful and 
explicit directions must be given as to the care of the excreta 
in order to prevent its spread to other members of the family. 
Crude carbolic acid should be added to the feces before it is 
emptied, and all vessels and utensils used by the patient should 
be used by him exclusively and boiled each day. 

A tub containing a 1/3000 bichloride of mercury solution 
or a 1/20 carbolic acid solution should be provided, in which 
the bed linen is soaked before it is washed. It should not be 
washed with the other household linen. Squares of soft cloth 
or gauze should be used instead of handkerchiefs, and these 
burned when soiled. 

Management. The presence of fever from any cause in a 
child is an indication for it to be kept in bed, but especially so 
when typhoid fever is suspected. The best room in the house 
should be chosen, with bath room and toilet conveniences nearby. 
No matter how young the child it can be kept in bed, and if it 
is put in charge of a nurse who is gentle, yet firm, this can 
be accomplished. It is rare that the youngest patient has to be 
taken up and held. Its position should be frequently changed, 
not allowing it to lie long in any position. It should not be 
allowed to get up to the vessel, but should be taught to use 
the bed pan. "No company should be allowed, no one in the 
room but the nurse and mother. 

A bedside record is an essential in the conduct of a typhoid, 
and a temperature chart or tracing just as important. In no 
other way can the run of the fever of a typhoid be so accurately 



GENERAL DISEASES 313 

kept track of as by the use of the temperature chart. Tempera- 
tiire, pulse and respiration should be taken every four hours. 

The child's eyes should be protected from the direct light, 
but the room should he bright and airy, the temperature not 
more than 65° or 70° F. The bed should be comfortable, pushed 
away from the wall so as to be approached from all sides, with 
a firm, but not too hard mattress. The mattress should be pro- 
tected by a rubber sheet, but plenty of thicknesses of sheets or 
pads to protect the skin, other^vise a sudamina or heat rash 
will be caused from the rubber sheet. The gown and sheet 
should be kept free from wrinkles at all times. 

A daily general soap- and water-cleansing bath should be 
given, as nothing so adds to the comfort of the child. This 
should be given irrespective of the baths given for temperature. 
The judicious application of a 50 per cent solution of alcohol 
to the hips and back v\^ill prevent bed sores developing. 

The mouth and teeth should be carefully watched and washed 
at frequent intervals. A very pleasant mouth wash is the 
following : 

I^ Glycerine oiss 

Listerine oss 

Lemon juice 3ss 
M. ft. Mouth wash. 

The mouth should be rinsed after every feeding and the 
mouth wash used in the interval. 

Diet. 'Eo other phase of the management of typhoid is so 
important and so difficult to control as the feeding of the pa- 
tient. Milk as an exclusive diet in typhoid is not well borne. 
It offers an excellent culture medium for the organisms which 
are found in the intestine with the typhoid bacillus. The same 
objection obtains in the exclusive use of the animal broths also, 
as they do not meet the demands of the nutrition. If milk is 
well borne it should be well diluted, with a loiu fat percentage. 
Frequently a fat-free buttermilk is well borne and relished. It 
may be necessary to peptonize the milk if there are evidences 



314 THE DISEASES OF CHILDREN 

that the proteids are causing an irritation. If a diarrhea begins, 
the milk should be withdrawn. Dr. F. W. Werner of Joliet, 
111., recommends strongly the exclusive use of hot, weak tea, 
claiming for the tea that it is bactericidal, and the fluid and 
slightly stimulating effect of the tea are beneficial. 

Food should be liquid and given at regular intervals, and in 
less quantity than in health. Three to four ounces every four 
hours during the day and twice during the night is ample, with 
a liberal amount of water between. 

Cereal decoctions, dextrinized, are well borne, and usually 
taken with a relish. They can be flavored with the broths, beef 
juice or with sherry, if not otherwise well taken. 

Stimulation. Stimulants should never be given as routine, 
but reserved until they are absolutely indicated, as they fre- 
quently are late in the attack. When the heart beat is weak 
and flagging or dicrotic, alcohol is of decided beneflt, especially 
when the second sound of the heart is muffled or weak. Only 
the best-bottled-in-bond article of whisky or equally good brandy 
should be selected. Children stand whisky well and respond 
to its effects quickly. A half to one teaspoonful well diluted can 
be given to a child of one year for its effect, every three or four 
hours. Digitalis (2 to 5 min.), strophanthus (2 min.), both 
in the form of the tincture; sulphate of strychnine f 1/200 gr.) 
by the mouth or hypodermically to a child of two years, or nitro- 
glycerine (1/500 gr.) in emergencies. 

Fever. A temperature below 103° F. does not need any 
special treatment, but when it rises to 103° F. or over it should 
be reduced. Coal-tar antipyretics should never be given, and 
resort must be had to hydrotherapy, which can be administered 
by the sponge, tub or pack. If the child is under two years of 
age it can be put in the tub without trouble, but a tub bath is 
difficult to give to older children without extra assistance. Low- 
ering the child into the water on a sheet stretched across the 
tub will often be of great assistance. The water should be 
warm, 85° or 90° F., and cooled from 5° to 8° by adding 



GENERAL DISEASES 315 

cool water at the foot of the tub and thoroughly mixing. The 
bath is prolonged for 10 minuteS; or a shorter time if there 
is shock or much nervousness and crying. The constant gentle 
friction of the legs, arms and body, avoiding the abdomen, 
will make the bath much more efficient, and a drop of 2"^ or 3° 
generally results. The application during the bath of a cold, 
wet compress to the child's head is of assistance. 

The sponge bath is often equally as efficient as the tub bath. 
The child is placed between blankets, and first one member and 
then another is exposed and bathed with a piece of gauze thor- 
oughly wet, but not dripping, in water of 85° or 90° F., with 
long, slow strokes ; then the back, first gently turning patient on 
the side, and lastly the abdomen and chest. The whole process 
should occupy from 20 to 30 minutes. The pack applied ac- 
cording to Kerley is very efficient. The jacket or pack, long 
enough to reach below the knees, with arm holes, is put on the 
child dry, and with a large sponge the water, at 90° F., is 
mopped on the pack until it is thoroughly wet. As the pack 
dries, fresh water is applied, gradually cooler, and the pack 
continued until the temperature is reduced. The temperature 
of the child should be taken at least haK an hour after the 
bath and finding recorded. The drop, as shown on the tempera- 
ture chart, should be indicated by an S^ indicating a sponge, 
or Bj for bath. 

Bowels. As a rule constipation is present during typhoid, 
and much more to be desired than diarrhea. The place which 
intestinal antiseptics occupy in the treatment of typhoid fever 
is a moot one. Personally I never employ them, and my results 
have been as good as my confreres who use them. Enemata of 
saline solution is usually all that is needed to obtain an action 
from the bowels, and they should be given regularly. An occa- 
sional dose of castor oil is of great benefit or small dose of 
cascara, 20 or 30 drops, of any of the aromatic preparations. 

What constitutes a diarrhea is a matter of individual opinion. 
More than three movements, if thin, should be considered ab- 



316 THE DISEASES OF CHILDKEN 

normal and call for treatment. If thin and containing undi- 
gested food, a preliminary dose of castor oil should be given, 
followed, when it has acted, with bismuth subnitrate (gr. x or 
gr. XV every three hours). Morphia is rarely indicated, but 
may be needed in very small doses. 

Tympanites. For the dry tongue and tympanites of the third 
week, no drug can take the place of turpentine, both internally 
and locally. It is difficult to give internally to a child, either 
in an emulsion or otherwise, but can be used as a stupe as 
follows : 

Iji 01. terebinthinae 3i 
01. olivse §i 

M. Sig. Rub one teaspoonful over the entire abdomen, and place over this 
the hot wet flannel, which should be renewed at half-hour intervals. 

The stupes should be watched closely as there is danger of 
producing strangury if they are kept up too long at a time. 

Internally, turpentine can be given in 3 to 5 drop doses in an 
emulsion flavored with peppermint. 

Hemorrhage. This is the most alarming of any complication 
which may arise. If the blood passed is black and no perceptible 
impression has been made upon the pu.lse, no special active treat- 
ment except starvation is required, but if the blood is bright, 
and there is a coincident fall in the temperature and rise in 
pulse rate, active measures are indicated at once. The foot of 
the bed is raised, an ice bag or coil is applied to the abdomen, 
morphine is given hypodermically (gr. 1/60), and all food and 
water is withheld in order to stop the peristalsis. Gelatin by 
the mouth and subcutaneously is of benefit in profuse hemor- 
rhages, and if doubly sterilized, risk from infection from hypo- 
dermic use is obviated. Its use in other hemorrhagic conditions 
has been so successful in my experience I would be tempted 
to use it in every case. Feeding is resumed very tentatively. 

Convalescence. This is a most important period, especially 
as to diet, and the patient must be constantly curbed and watched 
in order to prevent overdoing and a possible reinfection or 



GENERAL DISEASES 3l7 

relapse. The diet should continue the same until the tempera- 
ture has been normal a week, except more can be given at a 
time, when the following list can be followed for a child of 
three years or more : 

First Day. To take the place of one liquid feeding, a thick 
gruel of strained oatmeal. 

Second Day. Rice and milk. 

Third Day. Boiled custard. 

Fourth Day. Milk toast, crust cut off. 

Fifth Day. Baked potato, thoroughly mashed. 

Sixth Day. Soft-boiled egg, one feeding rice. 

Seventh Day. Scraped beef, broiled lightly. During first 
part of the second week the same articles can be given, only 
two in one day, and during the latter part more. 

RHEUMATISM. 

Etiology. The specific cause of rheumatic fever or rheuma- 
tism has not been located, but the clinical symptoms point to 
some cause of an acute infectious nature, and the finding of a 
diplococcus, practically identical, by both Triboulet and Was- 
serman, is confirmatory of this theory. That it can be due to 
uric acid or lactic acid does not seem probable. 

The association of tonsillitis and pharyngitis with rheuma- 
tism, or these conditions being a manifestation of rheumatism, 
must be borne in mind. 

It is infrequent in infants under two years of age ; from this 
to five years the course is very unlike rheumatism in the adult, 
and may go unrecognized. In older children the history is 
much the same as in adults. ITo joint involvement may be 
present. 

Exposure and fatigue predispose to an attack. Relapses and 
recurrences are frequent. 

Pathology. All of the serous membranes of the joints and 
of the heart may be affected. There is a congestion and swell- 
ing, with effusion both in the joint and in the surrounding cellu- 



318 THE DISEASES OF CHILDREN 

lar tissue. The frequency of involvement of the endocardium 
in children is much greater than in adults. The pericardium 
is not infrequently involved also. The involvement of the 
heart occurs often when there are but few joints involved, and 
they but slightly. The changes in the heart may precede the 
arthritis. The change in the heart is the result of the action 
of the infective cause of the rheumatism, either bacteria or their 
toxins, chiefly affecting the membrane lining the valves. The 
mitral valve is the most frequently affected. As a result of the 
action of the bacteria, a hyperplasia of the tissue takes place 
with the formation of vegetations on the valve. This prevents 
the free closure of the valve, and as a result an obstruction 
to the flow of the blood current or a regurgitation. 

Symptoms. These may be so mild as to pass unrecognized. 
The child may complain of vague pains in the joints and limbs, 
which are ordinarily called ^'growing pains," but which are not 
infrequently associated with serious and severe heart lesions. 
Hence, any joint pain in a child should not be treated lightly. 

In typical attacks, of the adult type, there is a chill or rigor, 
followed by an elevation of temperature from 102° to 105° F. 
There is languor and lassitude, followed shortly by pain and 
swelling of the joints. The number of joints affected vary 
greatly, occasionally only one or two of the large joints are 
involved, though all may be swollen and tender. One of the 
large joints, as the knee, and several of the smaller joints may 
be involved at one time. 

It is in those cases with insufficient pain to keep them in 
bed that the most serious involvement of the heart is seen. The 
pulse may be irregular and of less volume and a physical ex- 
amination of the heart reveals the beginning heart lesion. Herz's 
arm test is a good method of learning the functional capacity 
of the heart. The elbow is supported by the hand, and v/ith 
the free hand the wrist of the patient is grasped and the child 
told to make slow flexion of the forearm. The examiner does 
not resist this movement. Extension is then made as slowly, 



GENERAL DISEASES 3l9 

the child coucentrating his attention to these acts. The pulse 
is then counted and compared with the count made immediately 
previous to the test. If the myocardium is not absolutely sound 
the pulse rate is slowed and the size and strength of the pulse 
wave. One drop of the tincture of digitalis can be given a 
child of seven years, and if the myocardium is not normal there 
will be a difference in the pulse wave and rate from that pre- 
vious to its ingestion. 

Duration. The acute symptoms usually last from a week to 
10 days, though the pain may continue some time longer. 

Complications. Tonsillitis occurs with or may precede by a 
few days- the acute symptoms of rheumatism. In fact a severe 
attack of tonsillitis may be the only manifestation of rheuma- 
tism, and be followed by an endocarditis, hence an attack of 
tonsillitis or pharyngitis should be regarded with suspicion. 

Chorea is closely allied to rheumatism, and may occur during 
the attack or follow it. Close questioning in cases of chorea will 
usually bring out a previous history of rheumatism. 

Suhcutaneoiis nodules occur in the fibrous or connective tissue 
of the skin, from the size of a pin head to a small pea, being 
scattered particularly over the ends of the long bones and the 
vertebrae. They may not be visible on superficial inspection, 
but are easily felt on palpation. They are not painful or 
tender. ]N^o satisfactory explanation has been offered for their 
appearance. 

Various shin lesions may appear during an attack of rheuma- 
tism. Sudamina and miliaria, the inflammatory form of sudam- 
ina may develop because of the over-active sweat glands and the 
acidity of the secretion. Erythema nodosum is of rather fre- 
quent occurrence. These nodes appear principally upon the 
anterior surfaces of the tibia, are the size of a bean, discolored 
usually, and are quite tender on pressure. They may persist 
after the subsidence of the acute pain. They occur more fre- 
quently in females. Purpura hemorrhagica may be present, 
with petechial spots or larger hemorrhagic subcutaneous areas 



320 THE DISEASES OF CHILDREN 

here and there. Herpes and urticaria are uncommon but do 
occur. Peliosis rheumatica, Schonlein's disease, consists of red- 
dish, raised papules, which are purpuric. 

Pulmonary lesions are not uncommon, especially bronchitis 
and bronchopneumonia. They are probably of septic origin. 

The anemia^ which is always present to a certain extent, may 
become quite marked, and in the convalescence prove of some 
moment in the ultimate complete recovery. 

Diagnosis. This is principally from scorbutus, rachitis, ar- 
thritis, of septic, gonorrheic and tuberculous origin, and espe- 
cially in infancy these conditions must be ruled out. 

In a large percentage of cases of scurvy the first diagnosis 
made has been rheumatism, and frequently not until the soft- 
ening of the gums and hemorrhages of the subcutaneous tissue 
and mucous membrane, that the diagnosis of scurvy is made. 
In scurvy without complications there is no fever, which is a 
prominent symptom of acute rheumatism. 

The bony changes in rachitis, no fever, head sweats and his- 
tory should aid the diagnosis. 

In septic arthritis and osteomyelitis the general symptoms 
and condition of the patient is much more severe than in rheu- 
matism, and the lesion more centered in but one or at the 
most two joints at a time. 

Prognosis. As far as the risk to life is concerned the prog- 
nosis is quite good, provided there is no serious involvement of 
the heart. Recurrences are very frequent. A valvular inflam- 
mation may be present without permanent involvement or crip- 
pling of the valve, but owing to the possibility of recurrence, 
with little or no joint symptoms and severe heart involvement, 
the prognosis should be guarded. 

Treatment. The first positive indication is to put the child 
to bed and keep it at rest until all symptoms have disappeared. 
The diet should be largely liquid at first, with no meats or 
animal broths. Plenty of water should be insisted upon. Milk 
or any food in which it enters should be the chief diet. There 



GENERAL DISEASES 321 

are no objections to occasional feedings of the cereals, especially 
if a diastase be given afterward. With the subsidence of the 
fever, meat extracts or broths can be given, scraped beef and 
finally fowls and vegetables. 

The bowels must be carefully regulated, and if possible one 
of the salines given each morning. Sodium phosphate in half 
or full teaspoon doses, well diluted, is of benefit. 

The affected joints are made more comfortable if protected 
by the application of a cotton bandage, without pressure. A 
local application of a lotion suggested by Fuller is of service: 

I^ Sodium carbonate 3 vi 

Laudanum §i 

Glycerine 5ii 

Water §ix 
M. et. ft. Sol. 

The application of analgesique balm (Bengue) to the joints 
is also of service in allaying pain ; other remedies suggested are 
chloroform liniment and mesotan. 

Internally some form of salicylic acid is positively indicated, 
depending upon the condition of the stomach and its tolerance. 
Fuller also recommends the administration of alkaline reme- 
dies, the formula suggested being as follows: 

I^ Sodii salicylatis 3i 

Essentia pepsin (N. F.) 

Aquae dest. q.s. ad f § ss 
M. ft. Sol. 
Sig. One teaspoonful at a dose at two hours interval. 

Salophen in three to five'^grain doses is beneficial also. 

Aspirin in 3 to 5 grain doses. Salicin in 3 grain doses. Sal- 
ophen in 3 to 5 grain doses is beneficial also. 

After the acute symptoms have subsided, one of these prepa- 
rations should be given for a week or more, and the salicylate 
of colchicum, in the form of the Pil. Colchisal (Fougera) is of 
great benefit. 

For the pain and restlessness, opium in some form may be 



322 the'^diseases of children 

indicated, Dover's powder, morphine, codeine or heroin, in 

appropriate doses. 

Iron for the anemia in the convalescence is most important, 
and should always be given either alone or with cod liver oil. 
In the event a severe heart lesion develops the application of 
an ice bag to the precordial region is indicated. This allays the 
pain and discomfort of breathing and limits the amount of 
permanent involvement of the valves. Digitalis should be em- 
ployed only when indicated by failure of compensation, always 
judiciously and in as small doses as possible. 

When the patient is allowed to get up flannel underwear or 
a wool and cotton mixture must be worn in winter, and a thin- 
ner cotton underwear in summer, being careful to protect from 
exposure at all times. 

DIABETES MELLITUS. 

Definition. As in the adult this is a disease characterized by 
a polyuria charged with sugar ; thirst accompanied by wasting. 
It is not a frequent condition in children, but is rapidly fatal 
in the majority of cases. 

Frequency. Out of 3014* cases 394, or 13 per cent, occurred 
in children under 15 years of age. 

Etiology. It occurs infrequently before the end of the first 
year and more often between 5 and 10 years. Sex and race 
have little part in the causation, though slightly more females 
were affected, but heredity plays a decided part in it. Trauma, 
falls or blows upon the head have been suggested as a contribut- 
ing cause. Exposure, tuberculosis, the infectious diseases and 
a diet too rich in sugar and starches begun too early have been 
mentioned as causes. 

Wilcoxf found excretion of sugar in the urine after the in- 
gestion of from 15 to 20 grains of glucose, and concludes that 
children care for sugar as well if not better than adults. He 

* Wilcox: Archives of Pediatrics, September, 1908. 
t Loo. cit. 



GENERAL DISEASES 323 

puts the glucose capacity for the first ten years as 30 to 60 
grains. 

Pathology. Practically nothing of a definite nature is known 
of the pathology of this disease. A nephritis is often present, 
parenchymatous in type. The pancreas shows a variety of 
changes, atrophy, large, and either hard or soft, congested or 
normal. Calculus in pancreatic duct has been mentioned. 

Symptoms. Frequent urination is the principal symptom, 
with progTessive and often rapid loss of weight in spite of an 
increase in the appetite. The increase in the thirst is marked. 
Headache may be a prominent symptom and the child may be 
irritable and peevish, and there is usually an odor of acetone 
to the child's breath and secretions. The skin is dry and harsh 
to the feel. Loss of strength is in proportion to the emaciation. 

The urine is abundant, varying from 700 to 7000 cc. in 24 
hours, clear, and of a high specific gravity, and contains sugar 
and frequently albumen. The sugar varies in amount accord- 
ing to the time of day it is examined, lowest at night, highest 
at midday. Hyaline and granular casts are apt to be present, 
and have been considered a forerunner of coma. Acetone, dia- 
cetic acid, oxybutyric acid may be present and are of grave sig- 
nificance. 

The blood shows an increase in sugar. 

The duration in recorded cases varies from four days to two 
years. 

The child which may have been able to retain its urine all 
night begins to have enuresis and requires frequent changing 
both day and night. More urine is passed, usually during the 
day. 

Complications. Furunculosis frequently occurs, and pruritus 
is quite common. Tuberculosis is given as a common complica- 
tion. Diabetic coma is the usual fatal complication. Its fore- 
runner is the peculiar sweetish acetone odor to the breath, a 
cessation in the restlessness and increased hebetude and tendency 
to prolonged sleep. When the coma becomes profound its dura- 



324 THE DISEASES OF CHILDREN 

tion is. very short and a fatal termination prompt. Cyanosis 
follows the irregular breathing which soon sets in, the extrem- 
ities are cold and pulse weak and rapid. 

Diagnosis. This is not usually made early because of the 
failure to make urinalyses promptly in children's diseases. The 
association of symptoms should cause the condition to be sus- 
pected, viz., increase in the urine, thirst, increased appetite and 
wasting, and an examination of the urine to be made. 

Prognosis. This is always grave, as death follows very soon 
after a diagnosis is made. It is one of the most rapidly fatal 
of the diseases of childhood. The progress and course of the 
disease is best learned by the amount of sugar excreted, quantity 
of acids in the urine, the weight and amount of urine passed 
in 24 hours. 

Treatment. Breast feeding should be encouraged. Endeavor 
to find which form of carbohydrate is best borne. This is best 
learned by frequent urinalyses while the different starches are 
given. The presence of diacetic acid in the urine is an evi- 
dence that more carbohydrate is needed. Modified milk should 
be rich in fat content if no special acidosis is present, and sac- 
charin used instead of the sugar for carbohydrate content. 
Meat, eggs, in older children, animal broths and meat juices. 

Drugs offer but little hope of amelioration. Codeine sulphate 
is the only medicinal treatment of value. One of the forms of 
opium can be tried with arsenic. Benzosol in 3 grain doses for 
its effect on the intestine can be given. For the acidosis, the 
bicarbonate of soda is specially indicated. 

TUBERCULOSIS. 

Pathology. Every organ or tissue of the body is subject to 
the invasion of the tubercle bacillus. 

Glands. A proliferative inflammation takes place in the 
glands of the body, those situated near the most frequent port 
of entry of the infecting organism being the ones most actively 
affected, viz.^ bronchial^ cervical and mesenteric. The bacilli 



GENERAL DISEASES 325 

are carried through the lymph channels direct to these scaven- 
gers of the body. The following changes may occur in the 
gland: 1. Chronic proliferation of the gland tissue, enlarge- 
ment. 2. Degeneration, cheesy or fibroid. 3. Abscess, break- 
ing down of the gland due to infection with other organisms. 
4. Calcification. 

The tendency in these glands is to hold the infection as a 
local process, and is an evidence of the leucocytic fight being 
waged, an attempt of nature to prevent a general infection or 
an invasion into more vulnerable areas. 

The frequency of ■ postmortem findings of bronchial lymph 
nodes is significant of the possibility that the tonsils and respira- 
tory mucous membrane are most often the port of entry. 

Intestines. Tubercular ulceration here is the same as from 
other causes, and but for the surrounding glandular involve- 
ment or bacteriological examination would go unrecognized as 
such. The typical tubercle of the mucosa may be found. 

Meninges. The chief changes in tubercular meningitis are 
to be found at the base along the vessels, though miliary tu- 
bercles may be found scattered over the entire pia. The in- 
flammatory exudate may be quite thick and over the entire 
brain. The younger the child the more severe the inflammation. 

Kidney. The most frequent form of involvement here is of 
the pelvis of the kidney, the bacilli being easily demonstrated 
in the pus. Care should be taken to diflerentiate the tubercle 
bacillus from the smegma bacillus, which can be done by a 
more lengthy decolorization period. 

Port of Entry. A child being so much closer to the floor or 
ground when walking, and when younger being on the floor at 
play frequently, is much more open to infection from dust, 
infected toys and hands, than an adult. The infection may 
occur through the mucous membrane of the tonsil, even though 
unbroken, or carried directly to the lungs through the bronchi. 

The intestinal mucous membrane may allow the bacilli to 
enter without an abrasion being present^ and it has even been 



326 



THE DISEASES OF CHILDREN 



stated by one observer tbat pulmonary infection more frequently 
occurred from the bacilli gaining entrance tbrougb the intestine 
than through the bronchi. That it does so occur is proven 
beyond doubt. 

The lesion found may not be any guide to locating the port 
of entry. 







FIG. 44. 



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FIG. 45. 



TEMPERATURE FOR 81 DAYS IN CHILD WITH GENERAL TUBERCULOSIS, 
ENDING IN TUBERCULAR MENINGITIS. 



Ingestion of the infecting organism in milk must certainly 
be classed as one of the most frequent ports of entry. Infected 
milk and butter, nipples, toys, the mouth in kissing, dirt under 
the nails, are also conveyers of the bacilli. 

Frequency. During the first year less frequent than after- 
ward. Schwer found 14 per cent of the children autopsied be- 
tween 2 and 12 months to be tubercular. Cornet published 
result of analysis or records of Berlin Pathological Institute, 



GENERAL DISEASES 327 

which showed of 947 children dying between 1876-1891, 22 per 
cent showed tuberculosis; Still found 35 per cent in 769 post- 
mortems. The greater number of deaths occur between two 
and four years. 

Symptoms. The development of tuberculosis in children may 
be very insidious. In all forms the child shows a certain de- 
parture from normal, which is apparent to the careful mother 
or nurse. There is a listlessness or heaviness not ascribable to 
anything else. The appetite is capricious and the disposition 
variable, rather an inclination in sunny temperaments to tan- 
trums and moodiness. 

There is a beginning pallor, the flesh loses its firmness and 
the step its elasticity; and if weighed there is an appreciable 
loss. 

If glandular, the superficial glands of the body, formerly but 
little enlarged, increase in size; there is a slight rise of tem- 
perature, never quite reaching normal, or remains so but a short 
time of the day. A regular evening rise takes place. The ac- 
companying chart is the twice-daily ~ record of a case over a 
long period of time. 

Unexplained temperatures can frequently be explained by 
an ear which may be acutely inflamed without much pain, or a 
beginning systemic involvement with tuberculosis. 

Mouth breathing is frequently a prominent symptom, from 
a collection of adenoids in the nasopharynx, the tonsils are en- 
larged and the nasopharynx red. Exhaustion is easily produced, 
these cases having but little endurance. They will play vig- 
orously for a short while, but stop suddenly, lying down, per- 
haps, wherever they may be, often complaining of being tired. 

The pulse is not full, usually much quickened and ''irrit- 
able." Respiration is hurried, especially on the least exertion. 

Anemia is a prominent and early symptom, shown in a de- 
cided decrease in hemoglobin, and some diminution in the red 
blood cells. Very acute cases show a less blood charge than the 
more chronic ones. 



328 THE DISEASES OF CHILDREN 

Appetite is very changeable, at times good, at others very 
poor. Sweets are usually craved. 

With the development of pathologic changes in the lungs 
symptoms referable to this region appear. Cough, without ex- 
pectoration, except in much older children, as the young always 
swallow material raised from the bronchi or trachea. If pleurisy 
is present, there is usually pain and friction sounds over the 
area involved, and an examination will show signs peculiar to 
the advance of the degeneration. Bronchial glands may give 
impaired resonance or high-pitched breathing, if constricting 
either or both bronchi. If the process has been engrafted upon 
an unresolved pneumonia, the pneumonic signs persist with 
addition of signs of degeneration, localized fine, moist rales, 
with approach to cavernous breathing as breaking down occurs. 
The following history is a typical one of acute tuberculosis in 
a child: 

L. H., nine years old, was first admitted to the Masonic Home 
January 22, 1895, the physician's certificate stating that both 
parents had died of phthisis pulmonalis. 

Examination on admission showed hypertrophied tonsils, 
necrosed molar teeth and a peculiar listless expression. 

For some weeks after admission it was noticed that she was 
dull and apathetic, having little to do with the other children, 
apparently preferring to be alone. She had peculiar, expres- 
sionless eyes, with slight divergent strabismus of the left one. 

She was admitted to the infirmary on the 14th of April, hav- 
ing had a chill on the previous day. She was given 9 grains 
of quinise sulphas, daily for five days, after receiving 1 grain 
of calomel on the first day, with no effect upon the temperature. 
Examination at this time showed her to be very anemic and 
much thinner than on admission. She was content to lie quiet 
for hours, with a vacant stare, but would answer questions in 
monosyllables, never venturing a remark or making her wants 
known. 

On May 20 the following notes were made: Very pale, 



GENERAL DISEASES 329 

mucli wasting since admission; glands of neck, anterior and 
posterior, submaxillary and sublingual markedly enlarged, 
some to size of hazel nuts, some larger. Ing-uinal glands slightly 
enlarged to about the size of a pea. Abdomen relaxed, l^o mesen- 
teric enlargements made out. Harsh breathing found over pos- 
terior aspect of chest, otherwise negative. Some faucial con- 
gestion with tonsillar enlargements. 

Diagnosis of general tuberculosis with, perhaps, beginning tu- 
bercular meningitis. On May 23 she was seen by the con- 
sulting staff, Drs. P. B. Scott, J. G. Sherrill, J. G. Cecil and 
Frank Simpson, the diagnosis of general tuberculosis being 
concurred in. 

She was put on nourishing diet and tonic treatment. She 
would not stay out of bed, and gradually grew weaker from 
day to day. 

From June 23 she complained continuously of severe head- 
ache, crying out with pain. 

On July 1 she had a general convulsion, contractions of 
flexor muscles of arms and legs being present for some time. 
Both pupils were dilated equally. Large doses of potassium 
bromide were given without effect. 

During the night of July 1 she had many general convul- 
sions, lasting two or three minutes. During the morning of the 
2d she lay in a stupor, perfectly relaxed; she coughed consid- 
erably; the pupils were equal and the pulse regular. She died 
quietly at 3 p. m. 

Autopsy. On the morning of the next day, 18 hours after 
death. Rigor mortis marked. Body much emaciated. 

Chest. Lungs. Tubercular nodules and patches of tubercles 
distributed over the surface and borders of both lungs. Slight 
hypostatic congestion. Section shows apices thickly studded 
with tubercular nodules. Bronchial glands enlarged and in a 
state of fibrous degeneration, not cheesy. Most marked enlarge- 
ment of glands at bifurcation of trachea and along primary 
bronchi, ISTo pleural adhesions. Heart and pericardium nor- 



330 THE DISEASES OP CHILDREN 

mal. A lumbricoid worm 6 inches in length was found in the 
esophagus. 

Abdomen. Peritoneum and mesentery thickly studded with 
tubercles. Mesenteric glands enlarged and fibrous. Appendix 
vermiform is 3 inches long, lying in the right iliac region. 

Head. An excess of cerebrospinal fluid on opening calva- 
rium. Dura, normal. Brain (macroscopic examination by Dr. 
Carl Weidner) is large, symmetrical. The pia mater is rather 
firm. It is cloudy, in some portions distinctly yellowish, both 
at the convexity and at the base. At the vertex it can be de- 
tached without any difficulty. At the base it is markedly ad- 
herent in places, and especially so at the fissure of Sylvius. 
These adhesions are quite firm. In addition the pia shows some 
minute whitish-yellow, cloudy spots, and similar granules at 
the base of the anterior lobes, also an increased vascularity. 
Along the superior longitudinal fissure there are an unusually 
large number of Pacchinian granulations. 

The lateral ventricles having been torn open on a level with 
the corpus callosum (in transportation over rough streets after 
removal) contained no fluid. The cavities seemed large. ISTo 
signs of disease at the large basal ganglia. 

The medulla and cerebellum showed nothing abnormal. 

The case is reported principally on account of the interest 
attached to it in connection with the temperature chart, a 
record of the 80 days of acute trouble. 

Diagnosis. With the ordinary methods employed diagnosis 
of tuberculosis is at times a most difficult thing. Any contin- 
uous, irregular fever, in a child presenting the symptoms enu- 
merated above, especially anemia, loss of appetite and strength, 
which cannot be otherwise explained, is very suggestive of tuber- 
culosis. This is especially true when there has been a history 
of exposure. I have recently had under my observation a child 
in whom tuberculosis was strongly suspected because of a per: 
sistent temperature which was later found to be due to an in- 
volvement of the middle ears. 



GENERAL DISEASES 331 

The use of tuberculin for diagnostic purposes has recently 
been proven of great service. It can be employed in the form 
of a subcutaneous injection of the original tuberculin (Koch), 
by the conjunctival or the Calmette method, and by the cutane- 
ous method. 

In the, ophthalmic test the solution used is prepared as follows : 

The tubercuHn is precipitated by the addition of 95 per cent 
alcohol to concentrated T. O., or Tuberculin Original (Koch). 
The precipitate is collected on filter paper and washed with 
70 per cent alcohol until the filtrate runs clear. It is dried in 
vacuo over II2SO4 and afterwards ground into a powder. The 
powder is dissolved in sterile normal saline solution of 1 per 
cent by weight, heated in a water bath and filtered through 
paper. It is diluted as desired and filled into capillary glass 
tubes, which are then sealed and boiled for 10 minutes in a 
water bath. This insures a perfectly sterile solution, being 
instilled into the eye. 

Two solutions are employed in order to avoid unnecessarily 
severe reactions, 'No. 1 contains 0.5 per cent, and No. 2, 1 per 
cent. The J^o. 1 solution is used in one eye, and if no reaction 
is obtained in 48 hours No. 2 solution is used in the other eye. 
It is quite possible that the unpleasant effects reported in some 
cases is due to a too strong solution. Brown advises a 1:250 
solution in one eye and 1 : 100 solution in opposite. The method 
of application is as follows: One end of the capillary tube 
holding the solution is passed through the small rubber bulb, 
and a minute portion of both ends is broken off, and the tube" 
slipped back into the bulb. The end of the tube from which 
the drop is to be expelled is carefully wiped with sterile gauze 
or cotton to remove any spiculse of glass. The lower lid is held 
down, and by holding the tube parallel with the eye 1 drop 
from the tube can be squeezed on to the mucous membrane at 
the outer canthus. The lid is so held as to form a sac, the solu- 
tion being evenly distributed over the lid without allowing it 
to overflow on to the cheek. Occasionally a very slight smarting 



332 THE DISEASES OF CHILDREN 

sensation is complained of, but this is momentary. It is ad- 
visable to warm the tubes to body temperature if they have 
been kept in a cool place. The tested eye should be protected 
from external irritation, rubbing, wind, dust or smoke. 

The reaction described by Oalmette is seen on an average 
at about seven hours after the inoculation, though it may be 
delayed for 24 hours or even 48 hours. The first sensation 
is that of a scratchy feeling, lacrimation and redness, to a more 
severe one of severe injection of the conjunctiva and swelling 
of the lids. A stuffiness of the nostril on the corresponding side 
accompanied by a slight coryza. Park suggests the following 
classification of reactions: 

l^egative: 'No difference in the color when lower lids 
are pulled down. 

? Doubtful: Slight difference, with redness of caruncle. 

+ Positive: Distinct palpebral and ocular redness, with 
secretion well marked. 

+ + Deep injection of entire conjunctiva with edema of 
lids, photophobia and secretion. 

The reaction may continue for a week and gradually subside. 
In a small percentage of cases there is a slight rise in tempera- 
ture, but this is not often high. 

Both eyes should be closely examined before the inoculation 
to be certain there is no redness present. The presence of a 
distinct disease of the eye or lid is a contraindication for its use, 
as conjunctivitis, blepharitis, trachoma, iritis and keratitis. If 
a marked reaction is noted, the .conjunctivitis can be controlled 
by the use of a boracic acid solution wash, or a 2 per cent 
cocaine solution with or without a drop of a 1/1000 solution of 
adrenalin. 

The cutaneous method of diagnosis consists in a scarification 
like an abrasion for vaccination against smallpox, under the 
drop of tuberculin after the method suggested by Von Pirquet.. 
Two abrasions are made, about an inch apart, one being used 
for control, the control abrasion being made under a drop of 



GENERAL DlSEAS:ES 333 

50 per cent glycerine and .1 per cent phenol in normal salt solu- 
tion. A 100 per cent solution of Koch's original tuberculin is 
used. 

Wolff -Eisner describes the reaction in the cutaneous test as 
follows: The early reaction occurs in about three hours, be- 
ginning with slight redness which reaches its height in 24 hours, 
and has faded largely in 48 hours. In a few hours a papule 
appears, more plainly felt than seen, and in very occasional 
cases a bleb is formed. 

In the late reaction the redness and papule may be delayed 
until the fourth day, or increase gradually until the fourth or 
fifth day, and may persist for three or four weeks. -Enlarge- 
ment or tenderness of the glands in the axilla may be present. 
The reaction is described in this form as the normal reaction 
of the tuberculous individual; the late reaction, which may be 
marked strong or unusually strong; the quick, but very weak 
and fleeting reaction which may be overlooked. 

The subcutaneous method consists in the injection of 1/10 
mg. of the original tuberculin (Kock). If there is no reaction 
following its initial administration, a second dose may be given 
after a lapse of two or three days, gradually increasing by 1/10 
mg. doses up to 3 or 4 mg. Brown advises giving the injection 
at night, when, in a majority of instances, the reaction occurs 
in 8 to 20 hours. It may occur in four or five. Late reactions, 
second or third day have been noted. On this account the 
injection should be given every third day. A ^^reaction'' is 
evidenced by '^pain, tenderness, redness and swelling at the site 
of the injection, headache, malaise, an increased tendency to 
cough, probably more or less expectoration than usual, and at 
times some gastrointestinal symptoms as nausea and vomiting." 
There may be a rise in temperature also, and if this amounts 
to 2° F. it is fairly characteristic. 

Owing to the unfavorable reports of the opthalmoreaction, 
which are becoming more numerous, the cutaneous or vaccina- 
tion method is recommended as the most desirable test. 



334 THE DISEASES OP CHILDREN 

The laboratory is an aid to diagnosis of this condition in 
children, but owing to the infrequent successful attempts at 
obtaining a sample of sputum, and the difficulty of finding the 
bacilli in the feces, it is not as frequent an aid as might be 
hoped for. By closely examining the blood and mucus in sus- 
pected intestinal tuberculosis the bacilli may be found. In 
malaria or typhoid fever the organism peculiar to these condi- 
tions may be found. 

In tubercular pyelitis and cystitis the bacilli may be isolated. 
The smegma bacillus must be differentiated in the urinary ex- 
amination, the urine being obtained by catheterization per- 
formed in the most aseptic manner. 

Blood examination may show in the early stages an increase 
in the polymorphonuclear cells, later the mononuclears may 
predominate. 

Prevention. Prevention of tuberculosis in infancy is most 
important. The source of milk supply must be knovni, and 
only certified milk and inspected butter used. 

A child should never be allowed to come in contact with a 
consumptive, or to visit a house in which it is known there is 
a consumptive. Kissing children in the mouth should never 
be permitted. 

Treatment. The same general principles of treatment of tu- 
berculosis in children should be instituted as are employed in 
adults. If a sanitarium is possible, it will be found very easy 
to conduct the routine sanitarium life with a child. Children 
do not stand well either a very cold climate or a warm, enervat- 
ing one. Absolute rest in bed, in the open air, should be insisted 
upon at first, and exercise allowed very moderately and care- 
fully. This treatment is indicated in surgical tuberculosis as 
well. 

Children stand forced feeding when properly instituted, very 
well, indeed, milk and eggs being the best borne for the extra 
diet. 



GENERAL DISEASES 335 

The beneficial effect of tuberculin can be substantiated by 
a number of reported cases. The following case is an illustra- 
tive one : 

Tillie B., colored, aged 12 years, first seen with pleuro- 
pneumonia of supposed tubercular origin, which diagnosis was 
later verified by sj)utum examination. Degeneration progressed 
to the second stage, a small cavity forming in the right apex. 
She remained in this condition without great change for three 
months. At this time her cough increased, chills recurred daily, 
and the temperature ranged from 101° F. to 104° F. The 
subcutaneous administration of tuberculin, bouillon filtrate, was 
begun in dose of 0.000,000,001, gradually increasing at each 
weekly dose until at the end of eight weeks she was receiving 
0.000,001. The third day after the first injection the tempera- 
ture reached normal, and has since been above 99° I\ but once, 
and then only to 100° F. The same general measures were 
carried out during the administration of the tuberculin, viz., 
rest in bed out of doors, regular meals and eggs and milk in 
addition between. The improvement in this case can be at- 
tributed chiefly to the tuberculin. 

Medication is of secondary importance to a carefully regu- 
lated diet. Tonics undoubtedly have their indication, when 
judiciously employed, especially when there is a failure of 
appetite or a disgust for food. Cod liver oil can frequently be 
taken either pure or in emulsion to great advantage. Iron, the 
carbonate, citrate or muriated tincture, with or without malt, 
will be found of benefit. 

Baths followed by a general rub with olive oil or cod liver 
oil in the poorly nourished are most beneficial remedies. 

The importance of life in the open, especially for those chil- 
dren living in the close quarters of the poorer classes, cannot 
be over estimated. 



336 THE DISEASES OF CHILDREN 

PELLAGRA.* 

Pelle, shin; Agra, rough. 

This is a disease which prevails in the Southern States, not- 
ably North Carolina, South Carolina, Mississippi, Alabama and 
Texas. 

It is a toxemia, directly due to eating damaged corn, and is 
manifested by disorders of the nervous system, digestive sys- 
tem and localized erythemas of the skin. 

Pellagra has been knov^n since 1755, the first cases occurring 
in Spain, followed by others in Italy, France and Egypt. It 
has occurred in South America and Mexico, and in this country 
in Alabama, at the Mt. Vernon Insane Asylum, first reported 
by Dr. Searcy in 1906. Since this time many other cases have 
been seen. 

Etiology. Eating damaged corn is the direct cause of this 
disease. Bad hygienic surroundings and insufficient nourish- 
ment of other kinds are contributory causes. Corn is usually 
consumed in the South as cornmeal and grits, and these are 
moulded, containing fungi and bacteria. Searcy likens the 
condition under discussion to gangrenous ergotism, and believes 
the smut (ustilago) resembles the ergot of rye very much, and 
that corn smut is the cause of pellagra. 

The direct action of the sun's rays is believed to be a con- 
tributing cause of the skin lesions of pellagra, these occurring 
chiefly upon the exposed parts of the body. 

Symptoms. Cases of pellagra are either acute or chronic. 

The first symptoms of the acute form are a marked lassitude 
and weakness, followed by loss of flesh and varied gastrointes- 
tinal symptoms. The duration of this stage may be some weeks. 
The acute symptoms begin by a salivation and symptoms of indi- 
gestion, perhaps pain and tenderness in the epigastric region, 
followed by diarrhea. 

* I am indebted to the writings of Dr. Geo. H. Seacy, Tuscaloosa, Ala., 
for much of the data of this chapter. 



GENERAL DISEASES 337 

The skin lesions develop about this time, chiefly the exposed 
parts of the body being alfected, limited to the extensor surfaces 
of arm and hand, dorsum of feet, face and neck. The lesions 
are symmetrical. The appearance of the skin is a deep red, 
and a decided anesthesia in the part affected. The affected 
skin either forms bullae and blebs or becomes scaly and thick- 
ened. If the vesicles form they rupture and leave a denuded 
area which is moist. The nervous symptoms are soon manifest, 
not so marked in the early acute stage as when the disease be- 
comes chronic. The chief mental symptoms is a depression 
which grows more marked if the case becomes chronic. There 
is pain and tenderness in the dorsal region close to the spine, 
with exaggeration of the patellar reflexes. Later the reflexes 
are either lessened or absent. Insomnia is a marked feature 
from the beginning. 

The temperature may be elevated a degree or two, but is 
more often subnormal. 

The acute cases may prove fatal in a few days after they have 
to go to bed ; may lapse into a chronic condition or may recover. 
If recovery takes place the improvement is slow, taking several 
months to return to normal. 

In the chronic form there may be a history of an acute attack 
shortly before, or, as is more common, an attack during the 
previous summer. The skin, which has been the site of the 
eruption, is thick, wrinkled and scaly. 

The pronounced mental symptoms, depression and melan- 
cholia, usually do not become noticeable for a year or more, but 
as the disease progresses the mental symptoms are so severe as 
to necessitate confinement of the patient in an asylum. Demen- 
tia is the usual final outcome. 

Contractures are common late in the disease, of fingers and 
even of arms or legs. 

Diagnosis. The association of the following symptoms is 
sufficient to make the diagnosis : Location of erythema, vesicles, 
etc., on the extensor surfaces of the exposed parts of the body; 



338 THE DISEASES OF CHILDREN 

salivation, stomach disturbances and diarrhea ;- mental depres- 
sion, and the history of the corn diet. 

Pathology. Fatty degeneration of the internal organs ; pachy- 
meningitis and degeneration of the posterior nerve roots and 
posterior columns of the cord, and in the dorsal region, in the 
lateral columns, and the changes in the skin. There is also 
anemia and emaciation. 

General atrophy of muscles of body and the walls of the 
stomach and intestines take place in the chronic cases. 

Prognosis. A mortality of 58 per cent was reported at the 
Mt. Vernon Hospital. Death usually occurs within three weeks 
of the time the patient goes to bed. When recovery takes place 
it is slow. 

Treatment. The principal treatment is dietetic. Remove 
from the list of food all corn in any form. Give animal broths 
and milk. Do not keep the patient in a bright sunlight. 

Medicinally, arsenic is indicated. Searcy recommends it in 
the form of atoxyl, gr. iss doses, once a week hypodermically, 
increasing to 2 grains. 

MAIiARIA. 

By Wm. Britt Burns. "^ 

Synonyms. Malaria; ague; paludism; intermittent fever; 
paludisme (Fr.) ; Wechsel fieber {Gr.) ; paludismo (It.). 

Definition. A specific infectious disease, due to the invasion 
of the blood of several species of the hemosporidia of the genus 
Plasmodium malarise. The disease manifests itself, according 
to the species of infecting parasite, in three types, which are 
distinguished in common by the occurrence of periodical, inter- 
mittent or subintrant febrile paroxysms. 

* Dr. Burns while a resident near the swamps of Arkansas did a large amount 
of original work upon the subject of malaria, before taking up, in recent years, 
a general surgical practice in Memphis, Tenn. At the time the work of Ross, 
Grassi and Bastianelli was in progress, Dr. Burns checked it in his observa- 
tions. Dr. J. B. McElroy, of Memphis, has read the manuscript and corrected 
the proof of this chapter. 



GENERAL DISEASES 339 

Historical 'Note. Contemporaneous writers of ancient times 
c^hronicle the fact that malaria then existed. We learn from 
the writings of A. Groff that malaria was well known to the 
early Egyptians. The word '^Aat" occurring as an inscription 
on the temple at Denderah, is said to indicate the annual recur- 
ring epidemic. Our knowledge of malaria has been moulded 
for us by the acute observations and fairly accurate accounts 
of the disease by Hippocrates, Galen and Celsus, before the dis- 
covery of Peruvian bark (Cinchona), in 1640. 

With this period are associated the names and work of 
Sydenham, Torti and Morton. Torti and Morton divided the 
"essential fevers" into two classes, namely, those that were cur- 
able by treatment with cinchona bark and those in which it had 
no effect. Lancisi was the first to conjecture a relationship 
between malaria and the telluric, meteorologic and climatic con- 
ditions ; also to notice the very dark color of the liver at necrop- 
sies in fatal cases of malaria. In the eighteenth century de 
Haen noticed the rise of temperature during the chill. 

During the latter part of the eighteenth century rapid coloni- 
zation all over the world made the differentiation of malaria 
from other endemic tropical and subtropical diseases difficult 
indeed. The separation was satisfactorily accomplished in the 
nineteenth century. So that this epoch ends with the discovery 
of the malarial parasite by Laveran in 1880. 

The characteristic bodies having been found, the study of the 
mode of infection began to be hypothesized. !N"ott of Mobile, 
Ala., in 1848 published a paper on yellow fever, and in touch- 
ing on malaria wrote as if the mosquito theory had already been 
advanced. King in Washington in 1883 collected evidence; 
Laveran in 1891 ; Bignami in 1896 suggested that the mosquito 
might be the infecting agent. Koch claims to have thought of 
it in 1883-4. But Patrick Manson in 1894, was the first to 
offer argument in support of the "conjecture" as he called it. 

The third and grand epoch in the advance of our knowledge 
was opened by Surgeon-Major Ronald Ross of the Indian 



340 THE DISEASES OF CHILDREN 

Medical Service, who in 1895 began to elucidate and prove Man- 
son's theory, and in September, 1897, after examining a thous- 
and mosquitoes for both avian and human malaria. The Ital- 
ians, Grassi, Bignami and Bastianelli, in 1898, confirmed the 
work of Ross. 

Etiology. The plasmodium malarise, the infectious agent, is 
introduced into the human body, by the bite of mosquitoes of 
a certain variety, namely, anophelinse, which have themselves 
been infected by feeding upon individuals, whose blood con- 
tained sexual forms of the malarial parasites. 

The endogenous cycle or schizogony in a new infection be- 
gins with the sporozoites, penetrate healthy red corpuscles, 
barring phagocytosis, becoming trophozoites or ring forms, and 
later schizonts. These bodies feed upon the red cells, con- 
verting their hemoglobin into melanin, reaching their full 
growth ; the segmentation stage, or "roset" form, they divide by 
schizogony into a number of spores or merozoites. The rem- 
nant of the red cell, with its contained pigment, having dis- 
integrated, the merozoites are set free to attack other uninfected 
and occasionally infected red cells. The asexual or schizogonic 
cycle is completed. 

When the parasites are first introduced into the blood, their 
numbers are relatively small, hence for a certain length of time 
no symptoms are produced upon the host, the so-called incuba- 
tion stage, measuring from 6 to 12 days. During this, it is 
said, the schizogonic stage only is reached. About this time 
the reaction of the patient, as in the production of fever, appears 
to stimulate the merozoites to development into the sexual forms, 
namely, the male or microgametocyte, and the female or macro- 
isrametocyte. If the host is now bitten by the proper mosquito, 
these sexual forms, with other forms, are taken into its stomach, 
where the remnants of red corpuscles and their contained pig- 
ment and the asexual forms of parasites are digested, etc. The 
male cells put out flagella (microgamete) , which are, after a 
decided hammering motion, are thrown off, and finding the 



GENERAL DISEASES 341 

female cells (macrogamete) penetrate and fertilize them. The 
conjugation stage is called the zygote and the next step the 
ookinete. WTien this is accomplished, the ookinete pushes its way 
into the wall of the mosquito's stomach and begins its growth. 
The oocyst is formed; inside of which is developed, first, spor- 
oblasts; second, sporozoites. The oocyst is seen to be, in size, 
in proportion to the length of time between the feeding and 
death of the insect, namely: They may reach a greater size, 
according to Stephens. 

7 microns after two days 
17 microns after four days 
19 microns after five days, 
25 microns after seven days (Ross). 

The oocyst having reached its full development ruptures, and 
a large number of curved, thread-like bodies, sporozoites, escape 
into the surrounding serum. These bodies are now ready and 
tit to be introduced into the host. On staining, the sporozoites 
contain, centrally located, one or two small masses of nuclear 
matter, and measure 14 microns in length, tapering at either 
end. In the unstained, fresh specimens, they exhibit a decided 
writhing motion. 

Quartan Parasite. The quartan parasite is smaller than the 
enveloping red cell, when its segmentation stage is reached ; it 
causes the red cell to shrink and usually becomes darker in color. 
Its full development is accomplished in 72 hours. 

Beginning with the sporozoite or ring form (hyalin body), 
as a pale, refractory spot in the substance of the red corpuscle, 
usually eccentrically, about 1/TO the size of the containing cell; 
it feeds upon the hemoglobin, converting this into pigment and 
proper tissue. The pigment of the quartan parasite is char- 
acteristic, in that it is darker and in larger blocks or grains 
and lazier, than the pigment seen in the other varieties of 
Plasmodia. Between the hyaline stage and the segmentation 
stage, the different forms are merely larger parasites, with more 
and more pigment. The melanaemia of malaria is one of its 



342 THE DISEASES OF CHILDREN 

most characteristic features. Two varieties of pigment occur, 
namely, melanin and hemosiderin; the second is found in the 
internal organs and gives the reaction to iron ; the first is found 
in the circulating blood everywhere. The quartan divides into 
from 6 to 10 spores or merozoites. 

The Benign Tertian Parasite. Plasmodium vivax. The growth 
of the benign tertian parasite is exactly similar to that observed 
in the growth of the quartan; it is, however, very much more 
rapidly motile, the pigment is finer and keeps up a dancing 
motion, almost continuously. The containing red cell begins 
to swell early, and it becomes paler in color. The full-grown 
pigment bodies (schizonts) may, by the inexperienced, be taken 
for a pigmented or a granular leucocyte in the fresh blood. 
The segmenting body, both of the tertian and quartan, have the 
appearance of the daisy or marguerite. When the cell ruptures 
the remnant of the cell and its contained pigment are carried 
to the spleen. Segmentation occurs at the end of 48 hours, 
setting free 18 to 20 spores (merozoites). 

The Estivoautumnal Parasite (Laverania Malarice). The 
young forms of this variety of malarial parasite are somewhat 
smaller than either of the other forms; not so motile as the 
tertian, and does not show the amount of pigment of either. 
The full-grown bodies are about the size of the red corpuscle; 
at this stage they show several grains of rather coarse, black 
pigment. The segmenting body is divided rather symmetrically 
into from 8 to 25 merozoites. The sexual forms, ovoids and 
crescents (gametocytes), develop after a few days of the infec- 
tion. The staining reaction of all of these forms is quite 
characteristic : 

In a suitably stained preparation (using a chromatin dye) the young parasite 
appears to be a disk, consisting of a central, pale, unstained area, known as the 
achromatic zone, and of a basic (blue) periphery, the body, including a meta- 
chromatically stained, rounded, compact (red) , chromatin mass, the nucleus, 
which tends to give the parasite the form of a signet ring. Later stages up to a 
certain number of hours, show simply changes in size and outline of the body. 
The nucleus then divides by simple mitosis. Later it breaks up by amitotic 



GENERAL DISEASES 343 

division into an increasing number of angular pieces. By the time that chro- 
matin division is completed, the angular chromatin masses will have assumed 
a rounded form, and will be seen to exhibit ultimately the same strong affinity 
for certain dyes which is seen in the compact chromatin body of the young ring- 
like form — Park: Pathogenic Bacteria and Protoza.. 

'\'\TierL the parasite undergoes division the merozoites show, 
on staining, a chromatin mass with each achromatic body. The 
best stain is, probably, Leishman's or Wright's modification of 
Romanowsky's stain (eosinate of oxidized methylene-bliie), 
which is made as follows : 

LEISHMAn's modification of ROMANOWSKy's METHOD.* 

Leishman's method gives good results for general blood work, 
fixing at the same time as it stains. It has also the advantage 
that it stains the red blood corpuscles infected by the malarial 
parasite in a special manner. 

Solution A. One per cent medicinal methylene-blue (Grub- 
ler) in distilled water; add 0.5 per cent ^asCOs until alkaline. 

Heat to 65° C. in paraffin oven for 12 hours; allow to stand 
at room temperature 10 days before use.- 

Solution B. Eosin (extra B. A. Grubler), 1 gm. ; distilled 
water, 1000 cc. 

Mix equal volumes of A and B in a large open vessel; allow 
to stand for 6 to 12 hours, stirring occasionally. Collect the 
precipitate on a filter, wash with distilled water until the wash- 
ings become almost colorless, dry and powder the residue. 
(Grubler now makes this dye, and it may be also obtained in 
^^soloid" form from Burroughs, Welcome & Co.) 

To Prepare the Stain. Dried precipitate (green, metallic 
lustre), 0.3 gm. ; pure methyl alcohol (Merck "for analysis"), 
200 cc. 

The solution is of a dark-blue color, shows a greenish iri- 
descence by reflected light, and when kept in stoppered glass 
bottles does not deteriorate. 

^British Medical Joiu-nal: Methods of Morbid Histology and Clinical 
Pathology, Walker Hall and Herxheimer. 



344 THE DISEASES OF CHILDREN 

STAINING. 

1. Prepare a thin film. Dry in the air. 

2. Stain with 4 drops of dye for 30 seconds. 

3. Add to the alcoholic stain 6 or 8 drops of distilled water, 
and allow it to mix with the dye (by rotating the forceps). 

4. Allow the film to stain for 5 minutes (if film is very 
thick, 10 minutes). 

5. Wash the stain away with distilled water. Allow a few 
drops of water to rest upon the film for 1 minute. 

6. Dry in air or with blotting paper. Mount in xylol balsam. 
Red. Neutrophile, or fine eosinophile granules. 

Ruby Red. Nuclei of polymorphonuclear and mononuclear 
leucocytes. 

Pink. Red blood corpuscles. Eosinophile granules. 

Violet to Purple. Basophile granules. 

Pale Blue. Extra nuclear protoplasm of leucocytes and 
lymphocytes. 

Blue. Plasmodium malarise. Bacteria. 

If the red corpuscles appear bluish instead of pink, the pink 
color may be restored by washing the film in 1/1500 acetic 
acid solution. Heat may not be used to dry the film, as it 
breaks up the stain and decolorizes the chromatin. 

If a granular deposit is deposited on the films, remove it by 
washing quickly in absolute alcohol, the film, after a few seconds, 
being plunged into distilled water to stop the decolorizing effect 
of the alcohol. 

For Schuffner's and Maurer's ^^dots" stain with the mixture 
of stain and water for 1 hour, placing the preparation under 
a watch glass or the lid of a petri dish to check evaporation. 

Stain for 10 minutes or longer ; wash in water. Dry without 
using heat. 

The most common errors among beginners, in stained speci- 
mens, is the mistaking of a fragment of a leucocyte lodged 
upon a red cell for one of the ring forms of parasite. 



GENERAL DISEASES 345 

Blood Picture. In the hiunan blood there are only the nor- 
mal elements with which to confuse malarial parasites; these 
are, erythrocytes, leucocytes, platelets, products of coagulation 
and technique. In the fresh specimen, shrunken, spiculated, 
crenated red cells and shadow corpuscles are often mistaken 
for parasites. Vacuoles in the red corpuscles, and fragments, 
often round in shape, adherent to the red cells, are frequently 
confused with the young hyaline or ring forms ; thread-like 
debris for flagella. Large pigmented leucocytes may be con- 
fused with the full-grown pigment bodies of the benign tertian. 

Heredity. The question of heredity has been little considered. 
Duchek found a large pigmented spleen and pigment in the 
portal vein in a child dying three hours after birth, born of a 
malarious mother. Since the discovery of the plasmodium, Bein, 
Bouzian and Peters found the malarial organism in the blood 
of new-born infants; probably, however, such infants had had 
opportunity to become infected since birth. By analogy there 
seems to be no good reason to controvert the idea of transmission 
of the malarial parasite through the placental circulation. 
Germs proper to diseases such as charbon, chicken cholera and 
septicemia, etc., have been demonstrated in the embryos of ani- 
mals dead of these respective diseases. The typhoid bacillus was 
found in the lungs, spleen, kidneys and mesenteric glands of 
a child five days old, the offspring of a mother who had con- 
tracted typhoid fever in the eighth month of pregnancy. Trans- 
mission of syphilis is assumed as obtaining through the pla- 
cental circulation. Bignami, Bastianelli, Caccini, Thayer and 
Schaudinn have examined the blood of infants born of malarious 
mothers and placental blood, and they do not believe the trans- 
mission through the placental blood. Though necropsies of 
several fetuses from infected mothers have negatived the pre- 
sumption of heredity malaria, a positive conclusion is still not 
a violent one. 

Susceptibility. The greater liability of the child to get 
malaria becomes a question of easy solution when mosquito in- 



346 THE DISEASES OF CHILDREN 

oculation is accepted. The cliild is the first to be put to bed 
and is the first to sleep ; the arms and legs and maybe half 
the body are bare. The skin is delicate and tender, and as com- 
pared with the adultj clean, the exhalations from this organ 
lack the odor emanating from the adult. The adult does not 
retire until the mosquitoes have filled themselves from the blood 
of their children; they are better protected by clothing, shoes, 
etc., and they are better able to avoid the bites of these insects 
than the infant or small child. 

After an entrance into the blood current, the susceptibility 
is still greater in the infant. • The corpuscles upon which the 
Plasmodia feed offer less resistance; more of these bodies are 
destroyed, comparatively, at each paroxysm, than in the adult; 
consequently more toxins are liberated. 

Pathology. The benign forms of malaria do not produce 
many fatalities, and it is the pernicious or malignant type that 
supply our necropsies. The characteristic chocolate and slate 
color of some of the tissues and organs of the body, produced 
by deposition of the peculiar malarial pigment, is found in the 
subacute and chronic cases. Accumulations of malarial pig- 
ment, dead parasites, debris and pavementing of infected red 
cells occur in the vessels of the hrain, stomach, liver, spleen, 
kidneys and other organs, producing actual thrombi and necro- 
biotic areas in some of these organs. When it is considered that 
one-sixth or even one-third of all the red corpuscles in the body 
may be destroyed by one single, pernicious paroxysm, it will 
be understood that the above-named organs may become pro- 
foundly affected. 

Liver. The liver cells are thinned ; the capillaries are dilated 
and replaced by fat drops ; a great polycholia is denoted by the 
filling of the gall bladder; injection of the bile capillaries to 
their finest rootlets, l^ecrobiotic changes occupying rather ex- 
tensive areas are seen. The vessels are filled with pigmented 
leucocytes, dead parasites, remnants and debris, and blocks of 
yellowish-black pigment. Kupfer's cells and certain endo- 



GENERAL DISEASES 347 

thelial cells "undergo multiplication by karyokinesis. This 
hepatic tnmor has a blackish, leaden appearance, and is soft on 
section. More or less perilobular fibrosis obtains where there 
have been repeated infections. There is objection, however, to 
the idea of portal cirrhosis from malaria alone. 

Spleen. The splenic tumor may be merely palpable below 
the costal margins, or it may reach below the navel and to the 
anterior superior spinous process of the ilium. Postmortem, 
the surface of the spleen is dark, sometimes black; on se'ction 
the gland tissue is also found to be dark ; the parenchyma of the 
organ is much softened; the tarry pulp may be w^ashed away 
with quite a gentle stream of water. The pigment of malaria 
is here found within the endothelium of the arterioles and capil- 
laries in minute grains, often in actual blocks ; we find aggrega- 
tions of pigmented leucocytes, dead and breaking-down para- 
sites forming thrombi and actually occluding the vessels. The 
spleen and bone marrow have the distinction over all other or- 
gans of containing pigment in the cells of the parenchyma out- 
side and away from the blood vessels. ~ In these latter organs 
pigment is contained in ordinary leucocytes, but in the splenic 
vein this substance is included, not only in leucocytes, but also 
in certain large white cells identical with those occurring in 
the spleen, and evidently of splenic origin. 

Kidneys. The renal changes are not as severe as has been 
supposed, especially in the milder forms of malaria. Grossly, 
they. are slightly enlarged and pale in color. Small evidence of 
pigmentation. Microscopically, the glomeruli and the inter- 
lobular vessels are seen to contain infected red cells and pig- 
mented leucocytes. In the pernicious forms, and especially the 
hemoglobinuric form, the kidneys in the early stage of the 
disease are enlarged and congested; the tubules are blocked 
with hemoglobin infarcts ; the cells are loaded with yellow pig- 
ment grains, and the capillaries with black malarial pigment. 
The appearances are then those of the large, white kidney. The 
severest cases of nephritis of malarial origin are found in 



348 THE DISEASES OF CHILDREN 

hemoglobinuria. The capillaries in the medulla and papillae 
are often filled with infected cells and, parasites; while the 
tubules are filled with casts, in which are, sometimes, entangled 
infected red cells, parasites and pigmented leucocytes. Ewing 
reports a case of acute hemorrhagic nephritis of malarial origin. 

The Bone Marrow. Many sexual and pigmented forms and 
free pigment, pigmented leucocytes and macrophages harbor in 
the bone marrow. The small capillaries here are frequently 
choked. 

Respiratory Organs. The bronchitic and bronchopneumonic 
manifestations are seldom seen in the very young. I have, 
however, seen several cases, in adults, where there was spitting 
of blood and other signs of pneumonia, accompanying the par- 
oxysm, and which cleared up with the administration of quinine 
and the subsidence of the fever. 

Symptoms and Clinical Outline. It is the duty of the physician 
to carefully instil into the minds of the parents the grave im- 
portance of noting the little indispositions, of whatever nature, 
of the infant in a malarial region. A child does not cry and 
fret, does not refuse to nurse or eat, does not get nauseated or 
become restless at night, will not stop play for nothing. The 
mothers in the bottoms soon learn this. Eternal vigilance here 
is the price of liberty. 

There is no disease which may reach alarming proportions in 
children so stealthily as that of malaria — -yet so surely raises 
the danger signal, if one has been observant. 

We are to look for fretfulness, nausea, vomiting, stomachache, 
diarrhea, dysentery, epistaxis, excessive or scant urinary flow, 
drowsiness, fetid breath, coated tongue, headache, backache, 
feverishness and fever, etc. Any one or most of these symptoms 
may be present in a mild degree, one day, slightly more severe 
the next day — the third day (or even the second day) the blood 
is supersaturated with toxins, the nervous system is over-, 
whelmed, pupillary manifestations appear — one pupil dilated, 
the other contracted, the extremities are in clonic convulsions, 



GENERAL DISEASES 349 

the jaws are clinclied, unconsciousness comes apace. This is 
the eclamptic form, or the condition generally known as ''con- 
gestion/' from which so many babies die in the river bottoms 
of the South. Indeed, there is a general congestion, the most 
prominent symptoms may direct in one instance to the brain, 
in another to the liver, and still another to the stomach. The 
convulsions may be reflex in their nature, the point of irrita- 
tion which predetermines the flow of blood to a given organ 
or part being large accumulations of malarial pigment, dead 
parasites and debris, often occluding large vessels and lymph 
spaces. Often one sees families who have had born to them 
five, six, and even ten children, and only one, two or three of 
these live to cheer and brighten their homes, and in each in- 
stance one is told that all of these little ones perished with so- 
called malarial congestion. 

However, not all children suffer with acute malaria; a good 
percentage of them have chronic malaria, cachexia; one or tw^o 
mild chills ; quinine administered in mild doses just sufficient 
to prevent the next paroxysm, then given indifferently or not 
at all. The child goes on with considerable blood destruction, 
accumulating pigment, bile and malarial, their little skins take 
on a bronzed appearance, thickened and dry as parchment ; soon 
the spleen fills up and may be felt from 2 inches below the ribs 
to as low down as the iliac fossa, sometimes reaching across to 
the opposite side; its pressure upward on the diaphragm, with 
the pain which is often centered in the upper part of the organ 
similates, and the parents are often apprehensive of pneumonia. 
The liver is more or less to be felt below the costal margins. 
Sometimes there are black, tarry stools. But more often these 
are clay colored. There may be constipation, the rule, how- 
ever, seems to tend towards a looseness of the bowels, the color 
of the stools in this latter condition is that well known of "milk 
gravy." The urine is scant and scalding, highly colored and 
heavily loaded with solids ; occasionally there is a flow of clear 
(water colored) urine. This may be regarded as a manifesta- 



350 THE DISEASES OP CHILDREN 

tion of active malaria, and generally presages a paroxysm, how- 
ever mild it may be, followed by only a little back or leg pain, 
the Plasmodia may be sought in the peripheral blood. The 
tongue is large and flabby, indented by the teeth, with a whitish 
cast ; this, as are also the gums, is pale, anemic. 

Moncorvo believes that infants and children so infected are 
physically, mentally and morally deteriorated. He places 
malaria beside syphilis and tuberculosis, a retarder of physical 
growth. Every malariologist will attest that in the tropics and 
subtropics in the treatment of any disease, he has a malarial 
base to work upon, even in wounds which confine to the bed or 
room malaria is precipitated. My experience fully accords with 
that of Moncorvo. It requires no stretch of the imagination to 
say what three or four generations of these little bronze fellows 
will bring. It becomes quite a social problem, when our most 
fertile lands are so poorly habitable on account of this infection. 

The fatality^ according to L. Colin, of pernicious fevers, in 
an ascending scale is, icterus, comatose, delirious, cardialgic, 
algid and syncopal. As previously stated, the benign forms of 
malaria do not produce many deaths, and are therefore easily 
amenable to treatment. 

The hemoglobinuric form, upon which a great deal has been 
written, is, probably, only one of the very grave manifestations 
of pernicious malaria; the discussion of which could not be 
permitted by the space allotted here. 

What is the therapy of malaria? Every one knows how to 
treat chills and fever. Alas ! it is that character of knowledge, 
sometimes, of which it is said: ^'A little knowledge is a danger- 
ous thing.'' 

Prophylaxis. The preventive steps and safeguards may be 
summed up in the following paragraphs: 

1st. Every effort should be made to banish from the blood 
all Plasmodia. Especially should the blood of infants be made 
malaria free, because anopheles prefer to attack infants on 
account of a delicate skin. This may be accomplished by the 
proper and timely administration of quinine. 



GENERAL DISEASES 



351 



2d. All dwellings should be disinfected of mosquitoes, 
screened with close-wire netting, and extra precaution should 
be taken of placing close-gauze netting over each bed, and tuck- 
ing it in at the bottom. These bars should be inspected with a 
a good light, before retiring at night, to guard against infected 
anopheles, having stolen in during the day or left in from the 
previous night. 

3d. All trees and bushes should be cleared away for a large 
area around each dwelling, weeds and grass should be mow^ed 



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FIG. 46. MALAEIAL HEMOGLOBINURIA. 



closely once a week. Puddles and pools should be filled up, or 
if too large covered with petroleum. 

Mosquitoes cannot live in the summer sun, nor propagate 
without water. 

4th. Patients with malarial parasites should be isolated and 
carefully covered with netting so that anopheles may not feed 
upon such patients and, becoming infected, inoculate other per- 



352 THE DISEASES OF CHILDREN 

sons. Blood examinations should be made in all fever cases. 
The following is a report of a case of hemoglobinuria : 

This patient had a chill December 17. Quinin, in IsTo. 2 cap- 
sules, was administered every four hours until hemoglobinuria 
came on. 

December 19. At 11.30 a. m. the patient was comparatively 
comfortable, and slightly drowsy. The urine was dark. A 
smear of blood was taken and while examining it I was hur- 
riedly summoned. I found the urine the color of coffee. Both 
this and the first specimen responded to the guaiac-turpentin 
test. 

The first blood showed plasmodia. A second smear, taken 
after the urine colored up, showed plasmodia, estivo autumnal 
parasites in all stages of development, moderate poikilocytosis, 
a number of lymphocytes, leucocytes greatly increased, poly- 
morphonuclear and mononuclear phagocytosis. 

The lips and gums were pale, also the tongue, which is large 
and flabby, with a thick, white coat, and a tinge of brown over 
the back part. Icterus notably mild. 

At 1.30 p. m. calomel, gr. x, and turpentin, gtt. xx — turpen- 
tin in a beaten egg — were administered, to be respectively, until 
the urine cleared up. Quinin dihydrochlorate, gr. viiss, hypo- 
dermatically, was given at 1.30, 5 and 10 p. m., adding strych- 
nin, gr. 1/120, to each injection. At 10 p. m. the urine was still 
black. 

December 20. At 8 a. m. the urine was clearing up nicely. 
Calomel was replaced by sodium hyposulphite solution, gr. xx, 
every two hours. Beef juice was ordered, a half teaspoonful 
every two hours. Quinin bisulphate in hot solution was ordered, 
gr. X, every four hours. 

At 5 p. m. the dihydrochlorate, gr. viiss, was given hypo- 
dermically to avoid paroxysm. A tepid bath, containing a 
little sodium bicarbonate for a cleanser, followed by hot whisky 
and quinin, was given. Sponge and normal salt enema every 
four hours. 



GENERAL DISEASES 353 

At 11.30 a. ui. the urine was clear; turpentin was discontin- 
ued, and at 5 p. m. the condition was practically normal. 

At 10 p. m. the urine was quite dark. 

The blood contained numerous hjalin bodies, crescents and 
round bodies; leucocytosis was marked. There were a few 
lymphocytes; phagocytosis was marked, and there was an 
abundance of pigment and pigmented leucocytes. Quinin di- 
hydrochlorate, gr. xv, was given in solution. This was vomited 
and repeated immediately and retained. At midnight the fever 
was subsiding rapidly, and the urine clearing up slightly. Tur- 
pentin, gtt. XV, was given at 10 p. m., and repeated in 2 drop 
doses every two hours until urine cleared. 

December 21. At 8 a. m. the urine was clear, and there was 
no fever. The blood contained free pigment, pigmented leu- 
cocytes and debris, also two old crescents. Quinin bisulph., 
gr. V, and strychnin nitrate, gr. 1/200, in solution was ordered. 
Sodium hyposulphite and beef juice to be given every two hours, 
and a bath and normal salt solution every four hours. 

December 22. At 8 a. m. patient- was put on tonic and light 
diet. It will be noted that at 5 p. m., December 20, quinin, 
gr. viiss, was given hypodermically, yet the paroxysms came on 
at 10 p. m., at which time quinin, gr. xv, in solution by the 
mouth was administered and vomited, repeated at once and re- 
tained, and cinchonism was profound. This may be evidence 
of precipitation of the alkaloid by the alkaline tissues. 

Treatment. ^Vhen quinin for any reason is contraindicated 
we are almost entirely without a substitute; this very fortu- 
nately does not often occur. Quinine and the other cinchona 
derivatives exert a specific action on the plasmodia, and all 
forms of malaria respond to its action, if the case is seen in 
time. An infant or child should not be allowed to have a second 
or third chill even of the benign types. Pernicious paroxysms 
of every variety, icteric, comatose, delirious, algid, eclamptic 
or syncopal require heroic treatment, and should he met 
promptly by large doses of quinine hypodermically. 



354 THE DISEASES OF CHILDREN 

The necessity for a good liver arousement is here very urgent. 
For the spasms, chloral hydrate or bromide of potash, either 
or both, may be used ; it will be found that these will be often 
vomited; a hot mustard bath or a hot normal salt enema may 
be of value. 

For cachexia quinine in sufficient doses and tonics for 40 
days in connection with tonics. 

Bibliography. Thayer, Allbutt and RoUeson, Vol. II, Part 2. Minchin, 
AUbutt and Rolleson, Vol. II, Part 2. Stephens, Allbutt and Rolleson, Vol. 
II, Part 2. Ross, Brit. Med. Jour. Stephens, Mannaberg, Nothnagel, Vol. 
Malaria and Influenza. Deaderick for reprints. Burns, Hemoglobinuria; 
Mosquito as a Definitive Host in Malaria. Mosquito as a Definitive Host in 
Malaria — A Further Consideration. Some General Remarks on Malaria; 
Malaria, Quinin in. Infantile Malaria: Laveran New Sydenham Society, Celli 
and Craig. 

CONGENITAL SYPHILIS; LUES. 

A consideration of this subject is practically that of the con- 
genital variety alone, as acquired syphilis is rarely ever seen 
in infancy. 

Another phase of the subject of interest to pediatrists is the 
consideration of that form of syphilis in infancy termed tarda, 
which Fournier states may ''manifest itself at any age, from 
young, adult up to old age." 

Etiology. The recent investigations which have conclusively 
proven the spirocheta pallida to be the specific organism of 
syphilis have cleared up the etiology of this condition. This 
organism has been isolated and reproduced in the chimpanzee, 
and it has been found in the tissues of the syphilitic infant. 

The question of transmission of the syphilitic virus to the 
infant has been a moot one in medicine for years. Belief in 
parental infection direct, without infection of the mother, gave 
rise to CoUes' law in 1837, which was as follows: 

A new-born child affected with inherited syphilis, even though it may have 
symptoms in its mouth, never causes ulceration of the breast which it sucks, 
if it be the mother who suckles it, although continuing capable of infecting a 
strange nurse. 



GENERAL DISEASES 355 

In the light of modern knowledge of the etiology of syphilis, 
we know this law to be untenable. A¥hile the mother may seem 
healthy, she has become infected through the medium of the 
spermatozoa and ovum and is latently syphilitic, the syphilis 
being so mild in the mother as to escape observation. 

Mode of Transmission. The infection of syphilis may be 
carried to the embryo in the following ways : Direct from the 
father, through th<^ medium of the spermatozoa, there causing 
an infection of the mother, which may or may not be recog- 
nized. The time of greatest infectious possibility in the father 
through the spermatozoa is after the primary and acute sec- 
ondary manifestations. The greatest danger of direct infection 
of the mother is during the early stages., 

If the father becomes syphilitic after impregnation, infection 
of the fetus will be through the placenta from the mother direct. 

The infection may be from the mother direct, the father 
being healthy. 

If pregnancy is advanced some time in a mother not syphilitic, 
and she contract syphilis later in pregnancy, the child may be 
born healthy. The chance of a healthy child being born is in 
direct relation to the duration of the pregnancy. If both parents 
are syphilitic before pregnancy, the offspring will be syphilitic. 

Treatment of parents after infection makes possible a healthy 
offspring after such treatment. 

A syphilitic woman who has not been intelligently treated, 
will give a history of frequent early abortions or miscarriages 
before midpregnancy, or if progressed to full term will give 
birth to a syphilitic child. 

Pathology. Syphilitic changes in the placenta are fairly 
typical. The villi are much hypertrophied, and swollen vessels, 
some containing thrombi, are in the affected area. There is 
a fatty degeneration of the epithelial covering. In addition to 
this the spirochetge pallida have been found in the syphilitic 
placenta. The placenta is larger than normal. I^athan Lar- 
rier and Brideau* claim that spirochetes may be transmitted 

* Wall: American Journal of Obstetrics, June, 1908 



356 THE DISEASES OF CHILDREN 

between maternal and fetal structures, and vice versa, as fol- 
lows : 1st. A change in structure of the villus and the passage 
of the parasite through the mediation of perivascular infarcts 
with or without the intervention of leucocytes, a pathologic 
process. 2d. Transmission of the treponema by the prolifer- 
ating cells of Langhans a physiologic process, an important fac- 
tor because of the ability of the cells of Langhans to penetrate 
into the vascular systems of the decidua. 

The principal changes which take place in the fetus as the 
result of syphilis occur in the bones, certain of the viscera, the 
skin and the lymph nodes. In the hones there is an inflamma- 
tion at the site of greatest activity and growth, or a deposit of 
bony tissue on the shaft of the bone. When this inflammatory 
deposit occurs in the ends of the phalanges it is termed a 
daciylitis. 

The liver shows an interstitial change and usually is en- 
larged. There is a round-cell inflammation in the liver. Gumma 
may be found. The spleen is enlarged and also shows the same 
increased connective tissue as the liver. The same hyperplasia 
of connective tissue is found in the lungs and hidneys. The 
lymph nodes show a round-cell infiltration and enlargement. 

Symptoms. A syphilitic child may be prematurely born, 
macerated and covered with characteristic skin lesions, may be 
bom apparently healthy, with development of symptoms shortly 
after birth, or present no symptoms for weeks or months after 
birth, these cases being classed under syphilis tarda. 

In the second class of cases the symptoms usually develop 
during the first six weeks, and may be classed under those af- 
fecting the skin, mucous membranes and bones. 

The sMn will usually show a maculopapular syphilide upon 
the face, neck, hands and feet, and especially about the buttocks. 
The first skin disturbance may be found about the anus. This 
eruption may be discrete or confluent. When severe, occasional 
bullae or blebs may appear, and if they become infected, pustules 
appear, which form large crusts or scabs when they coalesce. 
Condylomata appear about the anus. 



GENERAL DISEASES 357 

Coincident with the skin lesion, sometimes antedating it, a 
coryza develops, the snuffles, which is quite characteristic of 
the condition. The snuffles is often preceded by an inflamma- 
tory condition of the posterior nares with profuse secretion, 
which is swallowed. The snuffles may be present at birth. There 
is a tendency for the mucous membrane at the corners of the 
mouth and at the anal margin to crack. When at the anus es- 
pecially they are termed rhagades. Mucous patches appear upon 
the buccal mucous membrane at this time also. 

An enlargement of the epiphyses quite regularly occurs of 
the long bones and the phalanges. These swellings may be pain- 
ful and tender. Dactylitis usually forms, and this may involve 
the metacarpal and metatarsal bones also. The parietal and 
frontal bosses are enlarged, and immediately behind the parietal 
eminences a thinned and softened bit of bone is found, the 
typical craniotahes. In a lesser number of cases craniotabes may 
be found in the occipital bone also. Softening and degeneration 
of the bones of the nose may occur. The spleen is quite regularly 
enlarged and easily palpable. It is .usually much larger than 
in other morbid conditions. The lymph nodes are very gen- 
erally enlarged. 

The child quickly develops into an anemic, run-down condi- 
tion. Because of the snuffles its nursing is interfered with and 
its nutrition is quickly impaired. It is anemic and a condi- 
tion of athrepsia soon intervenes. 

In syphilis hereditaria tarda, in which the symptoms may 
develop at any time from three months to puberty, the triad of 
symptoms as given by Hutchinson are interstitial keratitis, 
labyrinthine deafness and deformity of the upper incisor teeth. 
Corneal opacity is a result of the keratitis. The teeth may be 
peg shaped or notched, with transverse ridges across them. 

Gummata may develop at any place in the body, and not in- 
frequently they appear upon the skin. When in the brain or 
cord, symptoms referable to these regions develop. Synovitis 
is not infrequent. 



358 THE DISEASES OP CHILDREN 

Diagnosis. This should not be difficult in cases born pre- 
maturely, presenting the skin lesions and bony changes. Rickets 
may present some symptoms which are suggestive of syphilis, 
but the diagnosis should not be difficult. Rickets develops, as 
a rule, later, and the skin symptoms are not present. Later 
Hutchinson's teeth are confirmatory evidences of syphilis. 

Prognosis. The influence of syphilis upon infant mortality 
is not generally appreciated. Statistics* show a fetal mortality 
in paternal heredity under most favorable circumstances, of 28 
per cent; in maternal heredity, of 67 per cent, 86 per cent 
and 71 per cent, according to different observers, and in mixed 
heredity from 68 per cent to 86 per cent. Morrow states that 
one-third of all children born syphilitic die before they reach 
the age of six months. Syphilis then becomes one of the most 
severe of the scourges affecting the infant population. 

Treatment. If a diagnosis is made of syphilis in either 
parent, every means should be used to prevent conception. 

If pregnancy occurs in a mother who shows no signs of 
syphilis, if she is put at once upon an antisyphilitic treatment, 
which is conscientiously carried out during gestation, she may 
give birth to a healthy child. If she gives a history of frequent 
interruptions of pregnancy before term, from syphilitic causes, 
she may go to full term and give birth to a healthy child, pro- 
vided active treatment is undergone during the entire preg- 
nancy. The mother should nurse the child and continue treat- 
ment. A wet nurse should not nurse a syphilitic child. 

The treatment of a child, the subject of congenital syphilis, 
should be begun early and be faithfully carried out. It should 
be continued until the symptoms are decidedly improved and 
then discontinued for a week, then resumed for a period of 
three or four weeks. Gradually increase the interval between 
a course of treatments. The child should be kept under treat- 
ment for at least two years, better for three years. Mercury 

* Author's paper, Syphilis Affecting Infnat Mortality, Journal A. M. A., 1904. 



GENERAL DISEASES 359 

should be used in the early stages and can be given by 1, the 
mouth; 2, by the sMn, and 3, subcutaneously. 

In all forms of administration symptoms of saturation should 
be looked for. 

1. By the mouth, the following preparations can be used: 
a. Hydrargyrum cum creta (gray powder), in 1 grain doses, 
three times a day. The chalk usually controls the laxative effect 
of the mercury, but if it does not Dover's powder, \ grain, can 
be combined for its effect. The dose of gray powder can be 
increased later, h. Calomel, in doses of 1/30 to 1/10 of a 
grain, three times a day. Dover's powder, J grain, may also 
be used with this if it causes diarrhea, c. Bichloride of mer- 
cury, with sugar of milk, in 1/60 to 1/40 grain doses, d. 
Protoiodide of mercury, in dose of 1/15 to 1/10 grain. 

2. By inunction the following can be used : a. IJng. hydrar- 
gyri with equal parts of lanolin, a piece the size of the end 
of the little finger being rubbed twice daily, or about 5 grains 
of the mercury into the flexures of the body, alternately, h. 
Oleate of mercury, from 1 to 5 per cent, may be used in the 
same way, or as suggested by Rotch, saturating the binder with 
it and allowing it to be worn for 48 hours. Except in hospitals, 
this method of treatment is very unsatisfactory, and frequently 
severe dermatitis is caused by the inunctions. 

3. By injection, can be given bichloride of mercury in a 
2 per cent solution, 4 to 8 minims, every two or three days. 
This method of treatment is very impractical in children. A 
general supervision should be had over the feeding, habits and 
sleep of the patient. Breast milk is the best food, but not from 
a wet nurse. These children resist infections and illnesses very 
poorly, hence should receive the best nourishment and be pro- 
tected from contagions. 

Treatment of the Special Symptoms. The catarrhal condition 
of the nose causing the snuffles requires cleansing washes. Do- 
bell's or Seller's solution in spray or douche, followed by cal- 
omel insufflation or ointment (1 part to 20), or the ung. hydrar- 



360 THE DISEASES OF CHILDREN 

gyri ainmoniati, applied to the cavities. For fissures about the 
mouth and rhagades at the anus, dry calomel is of benefit. Diar- 
rhea may need treatment by discontinuance of the mercury and 
administration of bismuth alone, or combined with Dover's 
powder. 

Potassium iodide is given only when tertiary symptoms de- 
velop, hence late in the affection, and this drug pushed to point 
of saturation. 



CHAPTER XYI. 

Co2^TAGious Diseases. 

ACUTE EXANTHEMATA. 
MEASLES. 

Synonyms. Rubeola, morhilli, fleckern, masern. 

Definition. An acute, eruptive, febrile disease caused by a 
specific contagium. It is characterized by an eruption upon the 
skin and mucous membrane of tbe respiratory tract, and a 
catarrhal condition of these membranes, and fever. 

Etiology. Measles is perhaps the most contagious of the 
eruptive diseases, though the specific organism which is the 
cause of it has never been isolated. The organism is shorter 
lived, evidently, than the organism which causes the other con- 
tagious diseases. Occasionally a natural immunity is seen. 
Children under six months of age are less susceptible than older 
ones, and adults who have not had the disease in childhood may 
contract it. The contagious period exists throughout the whole 
course of the disease, though the acute catarrhal stage is sup- 
posed to be the most contagious. 

The contagium in cities rarely entirely dies out. It is very 
often endemic and frequently epidemic in character. Because 
of the closer housing of children in winter, and the schools being 
in session during these months, it is more prevalent in winter 
than in summer. Apparently it is possible for sporadic cases to 
develop without being able to trace the infection. It has been 
stated that the contagium cannot be carried through the medium 
of the second person or by means of toys, clothing, etc. 

The practice which is frequently seen in cities of mothers 
deliberately exposing their children to the contagium is one 
which cannot be too violently denounced. 

361 



362 



THE DISEASES OP CHILDREN 



Mason* has reported a case of measles in utero. The mother 
was delivered after a typical attack, during the stage of des- 
quamation, and the child showed a mottling of the skin and 
profuse general desquamation which persisted for 20 days. 

Symptoms. The symptoms are generally divided into three 
periods, that of incubation, prodrome or invasion, eruption and 
desquamation. 

Incubation. The duration of the period of incubation is from 
9 to 14 days, the eruption usually appearing about the four- 



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FIG. 47. MEASLES. 

teenth day after exposure. Usually there are no symptoms 
referable to this period, until 24 or 48 hours before the appear- 
ance of the eruption. 

The Period of Invasion. The first symptoms of this stage 
are usually those caused by the catarrh of the respiratory and 
conjunctival mucous membranes. These may be preceded by 
vomiting, slight headache, lassitude, and within a very short 

*Boston Medical and Surgical Journalj'October, 1908. 



CONTAGIOUS DISEASES 363 

time will be seen a corjza and reddening of the eyes, photo- 
phobia, a harsh, throaty cough, perhaps some hoarseness, if the 
larynx is involved, with more or less bronchitis developing later. 

JBeginning with the advent of the catarrhal symptoms, there 
is a rise of temperature, varying from 101° to 104° !F., reach- 
ing its height with the full appearance of the eruption. There 
is a slight morning remission of perhaps 1°, and the rise in the 
afternoon. There is an increased drow^siness and almost entire 
loss of appetite. 

Eruption. This is a dusky red, pin-head eruption, usually 
appearing hrst upon the sides of the neck and about the margin 
of the hair, then upon the chest and face, and gradually the 
whole body is covered. The eruption is much less prominent 
upon the lower extremities than upon the body and arms. It 
sometimes becomes confluent. It varies in color and is decidedly 
more dusky red than the eruption of scarlet fever. The rash 
may appear crescentic in form but the spots are usually irreg- 
ular in outline. 

In the very severe forms measles is sometimes designated as 
black measles, the eruption is of a bluish-black color which is 
due to the extravasation of blood under the skin. This form 
is also called malignant measles. 

The duration of the eruption upon the skin varies from three 
to five days. With its disappearance there is left a slight dis- 
coloration or mottling of the skin, which may remain for several 
days. 

Koplik has described a condition which is present upon the 
mucous membrane of the mouth, from 12 to 24 hours, before the 
appearance of the eruption upon the skin. This, as described 
by Koplik, is a bright red spot on the mucous membrane of the 
cheek and lips, in the center of w^hich is a minute bluish-white 
speck. This enanthem can only be seen in a good light, and 
the spots are very characteristic when found, and Koplik claims 
that they are pathognomonic of measles. 

The eruption fades first from the mucous membranes and 



364 THE DISEASES OF CHILDREN 

from the skin in the order in which it first made its appearance, 
and if the congestion of the skin has been very intense the des- 
quamation begins in small bran-like scales in the same order. 
This scaling has also been described as furfuraceons. The des- 
quamation is not at all regular, as frequently cases are seen in 
which no desquamation takes place at all. It is usually pro- 
portionate to the amount of temperature and severity of the 
rash. 

As the rash disappears, all of the symptoms gradually im- 
prove, the fever shows a regular decline, the cough improves, 
there is a slight return of appetite, photophobia disappears, 
though the eyes may remain weak for some time, and a mild 
conjunctivitis may also remain. The desquamation usually con- 
tinues from four to five days to a week. 

Atypical Cases. In an epidemic many varieties of cases are 
encountered. They may be so mild as to go practically unrec- 
ognized. The rash is very slight, there is very little fever and 
few catarrhal symptoms. Frequently, unless these cases occur 
in an epidemic, they go unrecognized. 

Malignant. This form is decidedly the most fatal and occurs 
in children with very little resistance. Eruption is very severe, 
frequently of the hemorrhagic type, ordinarily called black 
measles. Sometimes the malignant form may have but little 
rash, and the severe symptoms are caused by the severity of the 
complications. In this form of cases, pneumonia is the prin- 
cipal complication and the cause of the majority of the fatalities. 
In this the rash not infrequently disappears more or less rapidly. 
The laity look upon this condition as ^ ^striking in" of the rash, 
considering it the cause of the complication. This phenomenon 
is a result of the complication and not the cause. 

Complications and Sequelse. The chief coijiplications are those 
of the respiratory tract; bronchitis and bronchopneumouia. The 
younger the child, the more liable it is to develop pneumonia, 
and it is the most frequent cause of death. This complication 
is due to invasion of the respiratory mucous membranes by the 



CONTAGIOUS DISEASES 



365 



pneumococcus and the streptococcus, and in practically every 
fatal case of measles, more or less bronchopneumonia will be 
found. 



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FIG. 48. MEASLES WITH COMPLICATING PNEUMONIA. 



Catarrhal laryngitis and pharyngitis are very often present, 
and in these cases in which this is a feature an invasion of the 
middle ear is more often present. Otitis media is a frequent 
complication. It has not been my experience to see many cases 
of pseudomembrane upon the tonsils or pharynx in measles, 
though it has been frequently recorded by various authors. 
C onjunctivitis is a very frequent complication. There is al- 
ways a congestion of the conjunctiva and this may persist espe- 
cially in poorly-nourished children for some time after the dis- 
appearance of the rash. 

Tuberculosis. Eecause of the catarrhal condition and adenitis 
resulting from measles, the soil is ripe for the absorption of 



366 THE DISEASES OF CHILDREN 

the tubercle bacilli and their development. The frequent occur- 
rence of bronchopneumonia also offers a site for their develop- 
ment and propagation. The tubercular process may have been 
latent and an attack of measles all that was needed for its 
lighting up. 

Cutaneous Complications. A general pruritic condition of the 
skin may be present in measles, especially during the early 
eruptive stage. This may be partly due to a sudamina, or 
blocking of the sweat glands, and consequent formation of 
minute vesicles and great itching. Herpes labialis and facialis 
is frequently seen, and urticaria is also a complication. This 
may take the form of the large wheals or the minute papules 
which itch greatly. In the grave or hemorrhagic form noma 
may develop, due to an infective embolus finding lodgment in 
the cheek or perhaps an extension from an ulcerative stomatitis. 

Prognosis. This depends to a great extent on the individual 
child, on the character of the epidemic or endemic, the age of 
the child and the complications. The occurrence of pneumonia 
or any bronchial irritation renders the prognosis much less 
favorable. This one complication is the cause of the largest 
percentage of deaths in measles. 

The early evidence of toxemia makes the prognosis less 
favorable. 

The uncomplicated form of measles in a child over four is 
usually not very severe. 

Prognosis is bad in cases with such complications as laryn- 
gitis, otitis, diphtheria, hemorrhages in the skin. 

Diagnosis. With the first description of the buccal eruption 
in measles by Koplik, the diagnosis became much more easily 
made, for in connection with the catarrhal symptoms present 
the diagnosis can be made even before the rash has appeared. 

Rubella is apt to be confounded with measles, as the rash is 
very similar indeed. In this condition, however, all the symp- 
toms are less severe, less fever, very slight catarrhal symptoms, 
the rash appears more quickly and remains out a shorter time. 



CONTAGIOUS DISEASES 367 

and desquamation is rarely seen. The adenitis, postcervical, is 
a characteristic sign in rubella and not a constant one in 
measles. 

Scarlet fever is less apt to be confused as the rash is so en- 
tirely diiferent. There are but few if any catarrhal symptoms 
or cough in the early stages. The scarlatinal throat and tongue 
are not present in measles. 

Drug eruptions and the eruption due to an intestinal toxemia, 
the so-called "stomach rash," may cause some confusion in 
diagnosis. Rashes occur from the administration of antipyrin, 
quinin and chloral and the antitoxin sera. In all of these the 
catarrhal symptoms are absent, usually but little fever, and 
not suggestive of measles in its range. 

Treatment. Prophylaxis. As already stated, there is a wide- 
spread belief indulged in that all children should have the con- 
tagious diseases, unfortunately, by some physicians, and too 
many cities having the contagious disease placard system omit 
measles from the list of diseases to be reported and placarded. 

This lack of concern results in lax efforts at isolation and 
many unnecessary cases and deaths occur. 

Strict quarantine should be maintained and the child isolated 
as soon as a history of definite exposure has become known. 
Then when it is ready to be relieved of quarantine, when des- 
quamation has ceased, and no catarrhal symptoms persist, the 
final cleansing bath and room preparation should be insisted 
upon. 

Uncomplicated measles is a more or less self-limited disease. 
The curative measures will therefore be largely directed toward 
the prevention of complications. Hence, to prevent pulmonary 
involvement, the child must be kept in bed in a large, airy room, 
wdth plenty of fresh air. The light must not shine direct in 
the eyes, but there is no necessity of keeping the room entirely 
dark. The head of the bed should be turned toward the light 
and covered with a sheet to keep out the bright light. 

The eyes should be bathed at least twice a day with a 50 per 



368 THE DISEASES OF CHILDREN 

cent solution of boracic acid, warmed. The nose should be 
sprajed or irrigated with the same solution or with a normal 
salt solution. 

Fresh air should be insisted upon. The child should be pro- 
tected with sufficient clothing and outside fresh air let in. 

The harsh, dry cough which is apt to keep the child awake 
should be controlled. Moist air, obtained by keeping a steam 
spray going in the room near the bed by a croup kettle or steam 
atomizer is of great assistance to this end. To the water can 
be added tinct. benzoin comp. (3i to Oi) or oil of eucalyptus 
(3ss to Oi), both of which, in connection with the moist air, 
have a sedative action on the mucous membrane of the throat 
and larynx. Codeine in -J to ^ gr. doses, plain or with a tea- 
spoonful of brown mixture, can be used with great benefit 
for the cough. Wet, cold compresses to the throat, protected by 
a dry flannel, wider than the wet one, and changed every four 
to six hours, will be found of service also. 

If, during the early eruptive stage, there is great restlessness, 
3 to 5 grain doses of potassium or strontium bromide can be 
given at three-hour intervals. 

Unless there is hyperpyrexia the fever needs no attention. 
If it remains persistently above 103° F. it is best controlled by 
full-tub baths, wet pack or sponge baths. It is not advisable 
to give coal-tar products in any form. Enemas, when needed 
for acute constipation, should be given cool (70° to 80° F.) 
in the presence of high temperature. 

In those cases in which the eruption is slow in appearing 
a warm bath (100° F.) will be found of service. It quiets 
restlessness and favors the appearance of the rash. 

In measles, as in the other exanthemata, keeping the child 
wrapped up too warmly in a hot, unventilated room, and the 
withholding of cool drinks and giving hot or warm solutions in 
order to ''bring out the rash" should not be tolerated. 

While nephritis is an unusual complication in measles, it 
can occur upon exposure, and during convalescence the child 
should be protected from undue exposure to cold draughts. 



CONTAGIOUS DISEASES 369 

Bronchopneumonia is evidenced by a sharp rise in the tem- 
perature and an increase in pulse and respiration ratio and 
evidence of prostration. The treatment of this complication 
does not differ from a bronchopneumonia occurring primarily. 

Iron and cod liver oil are indicated in the convalescence, 
especially when a bronchial irritation and anemia persist. 

During the stage of desquamation the child should have a 
daily bath, in a tub if possible, and after drying should receive 
a general anointing with an unguent, a 1 per cent carbolic acid 
in vaseline. This is useful to allay itching and as an anti- 
septic also. 

RUBELLA. 

Synonyms. German measles, rotlieln. 

This is an acute specific, infectious, eruptive disease; usu- 
ally of mild nature, and of shorter duration than the other 
exanthemata, and not at all related to them. It does not pro- 
tect the individual from any of the others. 

Etiology. The bacteriology of this disease is not known. It 
may be sporadic but is usually epidemic, and may occur at any 
age. It is more frequent in children from two to five years of 
age. I have seen an epidemic of rubella and rubeola in an 
institution at the same time. A child would have an attack of 
one form, and in a few days return with a typical attack of the 
other. In some cases German measles preceded; in others 



Symptoms. The period of incubation is more variable than 
in the other exanthemata. The average is about 15 days, vary- 
ing from 5 to 18 days. There are, as a rule, no symptoms 
during this stage. 

During the stage of invasion, which may last from a few 
hours to two or three days, the child may be restless and peevish, 
complain of headache and sore throat, evidence some catarrhal 
symptoms, lacrimation and cough, but these latter are by no 
means constant. As a rule there is from 1° to 2° rise in tern- 



370 



THE DISEASES OF CHILDREN 



perature during this stage, the fever being higher as soon as 
the rash appears. Stage of eruption begins with the appear- 
ance of the rash on the face and neck, soon spreading to the 
trunk and arms, and finally very sparsely, as a rule, upon the 
legs, the rash reaching its height within 36 hours. By the 
time the rash appears upon the legs it has begun to fade on 
the face and neck. It is not unusual for the rash to have 
entirely disappeared within 48 hours from its onset. 



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FIG. 49. GERMAN MEASLES. 



The rash appears as a faint red macule, slightly larger than 
a pin head, and becomes a rose-red in color. There are areas 
of normal skin between the macular spots, unless the eruption 
becomes confluent, which is unusual. 

This is the variety of rubella which is usually referred to 
as the measles variety. 

The other variety is described as the scarlatinaform variety, 
the exanthem resembling that seen in scarlet fever. The differ- 



CONTAGIOUS DISEASES 371 

ence between the two forms of rubella are simply in tbe char- 
acter of the rash. In the scarlatinaform variety the rash is 
much more widely distributed, does not occur in such large 
macular spots, and the skin has a more uniform redness. 

In rubella there is almost constantly found an adenitis, the 
lymph nodes most frequently found enlarged being those of the 
neck, both back and front. This symptom occurs in fully 
90 per cent of cases, and is a valuable diagnostic sign, as an 
adenitis is not nearly so frequent in the other varieties of ex- 
anthemata. The swelling of these glands quickly subsides after 
the fever and rash disappears. 

Desquamation in rubella is not as regularly seen as in measles 
and scarlatina. Like in measles, the amount of the desquama- 
tion is proportionate to the severity of the eruption, and is 
bran-like and scaly, and is not prolonged, rarely lasting more 
than a week. The desquamation may be simply a roughening 
of the skin and not at all decided. 

Complications and Sequelae. These are very infrequent and 
rarely severe. A gland or group of glands may break down and 
require lancing to evacuate the pus. Stomatitis is sometimes 
seen, but is never of the gangrenous type ; pneumonia is much 
less frequent than in measles, and an otitis media may occur. 

Diagfnosis. This is frequentlv very difficult indeed. It must 
be made from measles, scarlet fever and vaccinia. When it is 
remembered that rubella is most apt to occur in epidemics, all 
its symptoms are less severe, rash not so profuse and more dis- 
crete; less fever; adenitis present in almost every case and has 
few complications or sequelae, the diagnosis is usually easy. 

Pro^osis. This is almost universally good, especially so 
where the hygienic conditions are all right. 

Treatment. But little treatment is required, confinement to 
bed during the eruptive stage, and while the fever lasts, in a 
properly ventilated and heated room : cleansing sprays and 
washes for nose and throat, attention to bowels ; bathing, both 
for cleansing and antipyretic purposes, and anointing during 
the stage of desquamation. 



372 THE DISEASES OF CHILDREN 

SCARLATII^A. 

Synonym. Scarlet fever, scharlach. 

Definition. An acute, specific, highly contagious and infec- 
tious/ eruptive, febrile disease. 

Etiology. The specific organism, the cause of scarlet fever, 
has not yet been isolated, but it is unquestionably due to an 
organism, and associated with it is the streptococcus in a large 
percentage of cases. It is the streptococcus which is the cause 
of so many of the complications of scarlet fever, and it is prob- 
ably the mixed infection which is present that accounts for 
the severity of so many cases. 

The contagium lives for a long period of time, and can be 
carried great distances by articles handled by the sick child. 
A number of epidemics of scarlet fever have been traced to 
milk as the carrier of the infection, and in every epidemic the 
milk supply should be closely investigated. 

Scarlet fever is most frequent between one and five years of 
age, though cases are on record in children much younger. It 
is rare before the sixth month. 

A natural immunity may exist. Second attacks are not lan- 
common. Adults are less susceptible then children. 

The discharges from the nose, mouth, throat and bronchi are 
most virulent as carriers of the contagium, the desquamated 
skin being also a disseminator of it. Hence, scarlatina is con- 
tagious throughout all its course. The port of entry of the con- 
tagium is most likely the nasopharynx. 

As in measles, because of the close housing and crowded school 
rooms, during winter, more cases occur in this season than dur- 
ing the summer months. I have never seen a case of scarlatina 
in a negro, and I believe it is very uncommon in this race. 

In spite of the long life of the contagium, scarlatina is not 
nearly so prevalent as measles. I have frequently seen one 
case of scarlatina removed from a dormitory of children with- 
out the second case developing, while measles would most likely 
have attacked every one. 



CONTAGIOUS DISEASES 373 

The mucus discharges xrom the nose and mouth and the des- 
quamated skin are-the chief sources of contagion. Hence, any- 
thing handled by the patient, especially during the stage of 
desquamation should be carefully disinfected or destroyed. The 
bedding from the child's bed, the clothes and night dress should 
be most carefully disinfected. 

Symptoms. Period of Incubation. This is usually shorter 
than the other eruptive diseases, lasting from a few hours to 
6 to 10 days. The onset of the stage of invasion is short and 
sudden, it appearing to attack a child apparently well. It is 
attended by sore throat, vomiting, rigors, fever, rapid pulse, 
headache and loss of appetite. The tongue is covered quite 
heavily with a grayish-white coat, with a cleaning off of the 
edges at the beginning of the stage of eruption. About this 
time also the red papillae begin to show through this coat, 
which at the tip becomes quite thin, giving to the tongue the 
appearance of a strawberry. This is considered a confirma- 
tory sign of scarlet fever. About the fourth day of the rash 
the tongue is clean and papillae quite prominent. At this time 
the tonsils are swollen and red; perhaps a slight exudate may 
have appeared on one or both. 

Stage of Eruption. The eruption appears usually within 24 
hours after the first symptom, which as a rule is the vomiting, 
is noted. It comes out on the neck first, and about the same 
time spreads to the chest and face, and shortly afterward the 
entire body is covered. It is more distinct on the flexor surfaces 
of the extremities than the extensors. 

The scarlatinal rash is a minute punctate elevation on the 
skin, with areas of normal skin between, but the skin has the 
appearance of having a uniformly dull red hue when viewed 
at some distance. This is due to the erythematous background. 
The skin is blanched on pressure, the red color promptly ap- 
pearing on removal of this. There may be large areas of normal 
skin, and the rash looks patchy. 

The rash disappears first from the parts of the body where 
it first appeared, leaving the skin rough, and this is followed 



374 THE DISEASES OF CHILDREN 

by a general desquamation. The eruption lasts from three to 
seven days, but undoubtedly cases are encountered in which 
the rash is so slight as to go entirely unnoticed. 

I have had such a case under observation. The prominent 
symptom was the gangrenous tonsillitis, and the boy was treated 
for this entirely. About 10 days later, after being dismissed 
with all symptoms in the throat absent, he consulted me again 
to ask why his hands were peeling, and exhibited a hand which 
had the typical scarlatinal desquamation, the skin coming off 
in large scales. 

Desquamation. This begins upon the parts where the rash 
first appeared. On the body the peeling is furfuraceous, the 
skin coming off in larger scales than in measles. These scales 
are perforated and they have been referred to as '^pin-holing." 

It begins with the subsidence of the fever. The typical 
scarlatinal desquamation begins upon the hands and feet soon 
afterward. Cases have been reported where entire casts of the 
hands and feet were thrown off. It begins at the free border of 
the nails. This form is referred to as a lamellosa. The finger 
nails show characteristic signs in this stage. If the skin at 
the matrix margin of the nail is pushed back a cracked line is 
noted extending up to the matrix. This is best seen on the 
thumb. E'o desquamation whatever may follow an unquestioned 
case. 

The duration of desquamation is from two to ten weeks, the 
average being about five weeks. 

Fever. There is no typical temperature curve in this disease, 
but it is high in proportion to the streptococcic involvement and 
reaches its height by the second or third day. If everything 
is progressing favorably the temperature begins to fall with 
the recession of the rash, and it rises with the development of 
any complications. 

The pulse is almost always found to be rapid, out of pro- 
portion to the temperature and respiration range. There is a 
general enlargement of the superficial lymph nodes, not limited 



CONTAGIOUS DISEASES 375 

as the enlargement is in German measles to the cervical region, 
but appearing in the groin, and axilla also. 

The throat is congested from the rash on the mucous mem- 
branes quite early, and an exudate is very often seen after the 
second or third day, principally upon the tonsils. These exu- 
dates may be due to the streptococci or to the diphtheria bacillus, 
and a culture is generally necessary to decide to which organisms 
it is due. 

The urine should be regularly examined during scarlatina. 
During the height of the eruption the quantity is reduced, but 
at the end of the first week it returns to normal. It is not 
uncommon for albumin to be present throughout the disease in 
small quantities and sometimes the renal derivatives, epithelium, 
blood, granular and hyaline casts, but they are found more fre- 
quently during the stage of desquamation. An acute Bright's 
disease is not regularly seen, but it does occur as a complication 
very frequently. 

Complications. Otitis. A purulent inflammation of the mid- 
dle ear is one of the commonest complications. It may occur 
in cases in which there is no tonsillar exudate, and a spontaneous 
rupture of the drum is nearly always the result. Scarlatinal 
otitis is one of the most frequent causes of deafness, and is a 
complication to be dreaded. Its presence is usually indicated 
by deafness, earache and rise in temperature, followed soon 
after by a spontaneous rupture of the drum. The presence of 
the pus in the auditory canal or the staining of the pillow 
noticed when the child awakens may be the first evidence of this 
trouble. 

Angina. This may be either a severe congestion of the 
mucous membrane of the throat, a severe tonsillitis with en- 
largement of the tonsils, a pharyngitis and laryngitis, or a 
gangrenous condition of the tonsils. It is not infrequent that 
scarlatina sine exanthemata is at first diagnosed as a simple 
catarrhal or a follicular tonsillitis, as an exudate in the tonsillar 
crypts is very frequent. Where the exiidate is very thick, late 



376 THE DISEASES OF CHILDREN 

in the eruptive stage, the chief organism is the diphtheria 
bacillus. The diphtheritic form usually reaches its height at 
the end of the first week, and the symptoms and appearance of 
the throat are the same as in uncomplicated diphtheria. 

Adenitis. The inflammation of the lymph nodes may be 
quite severe and suppuration may occur. This enlargement of 
the glands at the angle of the jaw and of the neck may be 
enough to cause pressure on the larynx and dyspnea, or the 
streptococcic invasion of the cellular tissue of throat and larynx, 
sufficient to necessitate intubation. I have had such a case 
under my observation. 

The child had a severe scarlatina with first a double sup- 
purative otitis media, then an albuminuria, followed by a mem- 
branous angina and an obstructive laryngitis. This condition 
necessitated an intubation which relieved the symptoms for a 
time only, the obstruction from cellular infiltration both above 
and below the tube being so great as to make the removal of the 
tube imperative. This was done with great difficulty. Dyspnea 
being decided and relief necessary to prolong life, an intubation 
was done. A bronchopneumonia developed at this time and 
death from heart failure relieved the sufferings of the child. 

Arthritis. A streptococcic inflammation of the joints is some- 
times seen, formerly diagnosed as a scarlatinal rheumatism. It 
is a synovitis of streptococcic origin. 

Kidneys. The kidneys are involved in scarlatina in a large 
percentage of cases, the symptoms appearing usually from the 
end of the second to the middle of the fourth week of the disease. 
A diminution in the quantity of the urine, edema of the eye- 
lids, face and ankles is noted, and an examination of the urine 
shows all the abnormalities found in the urine of an acute 
nephritis. Uremia may occur in the severer forms of nephritis. 

Frequent or daily examination of the urine from the begin- 
ning of the second week is desirable, as albumin will often be 
present before symptoms of the nephritis appear. 

Lungs. A bronchitis is not as frequent a complication in 



CON'xAGIOUS DISEASES 377 

scarlatina as in measles, but it sometimes occurs. Bronchopneu- 
monia is more often seen, especially in those cases in which the 
streptococci are present in large numbers. 

Other complications occasionally occurring are an endo- 
carditis, in those cases of streptococcic synovitis especially; a 
myocarditis in severe septic infection, as in gangrenous sto- 
matitis; meningitis in the course of the disease or follov^ing 
a mastoid involvement as a complication of otitis media; con- 
vidsions, either as an initial symptom or during the course of 
the disease; an irritable condition of the stomach, recurrent 
vomiting, anorexia, diarrliea, are not imcommon complications. 
Vomiting as the first symptom, occurs quite regularly, As 
sequeloe there may be a chronic tonsillitis with enlargement, and 
perhaps the development of adenoids; deafness, already re- 
ferred to ; mastoiditis ; chronic nephritis ; and endocarditis. 

Diagnosis. In the irregular forms of scarlatina with but 
little rash, which is of very short duration, the diagnosis may 
be very uncertain, as in the case of gangrenous tonsillitis re- 
ferred to, or not suspected at all, and not made until desquama- 
tion begins. 

The typical cases, however, should be easy of diagnosis. The 
associated symptoms are characteristic, vomiting, fever, typical 
rash, sore throat and strawberry tongue. 

Prognosis. In uncomplicated cases this is good. Holt gives 
the general mortality from 12 per cent to 14 per cent in uncom- 
plicated cases, and cases under five years from 20 to 30 per 
cent. Hence, the prognosis is greatly influenced by the occur- 
rence of complications and by the age of the patient. 

Treatment. Prophylaxis. Empirically we have learned that 
scarlatina is much less contagious than measles, and that the 
contagium is very much longer lived, hence the special indica- 
tions are strict isolation and quarantine of every case of scarla- 
tina, and most thorough disinfection after dismissal of the case, 
of room, bedding, dishes, clothing, etc. Isolation should begin 
as soon as it is known the child has been exposed to scarlatina, 



378 THE DISEASES OF CHILDREN 

even thoiTgh the exposure has been during the incubation stage, 
when it is believed the least danger is present. Other children 
in the house should remain away from school, and should not 
be sent away from home in order to continue at school because 
of the possibility of late development of scarlatina in them. A\] 
intercourse between the sick room and the rest of the house 
should be prevented, and the physician should protect himself 
by a long gown before entering the room and cover head with 
head gauze or cap. The gown should be taken off after leaving 
the room. The hands and face should be then carefully washed. 

Quarantine should be prolonged during the entire stage of 
desquamation, and not until the feet and hands are entirely free 
from roughness and scales should it be raised. The persistence 
of the discharge from an otitis or a chronic nasal discharge or 
pharyngitis is sufficient ground for maintaining the quarantine. 

Placarding of houses is most important and this regulation 
will be made a law if the physicians of a community demand it. 
The medical inspection of public school children is a measure 
which will prevent many epidemics of scarlatina and measles, 
as the early recognition of the sore throat of one, catarrhal symp- 
toms and buccal eruption of the other, will be enough to remove 
the child from the class long enough to have the tentative diag- 
nosis confirmed or disproved. Attention to details in the choice 
and conduct of the sick room should be given by the physician. 
A room as cheerful as possible should be chosen, but removed 
from the rest of the house, on the top floor, or at the back, near 
enough the toilet and bath room as not to necessitate the carrying 
through all the halls of the discharges, etc. All unnecessary 
hangings and the carpet should be removed. A tub should be 
provided in the room containing enough antiseptic solution 
(1/2000 bichloride or 1/20 carbolic acid solution), in which 
all bed linen and clothes can be soaked before they are removed 
to be washed. They should then be boiled separately from the 
rest of the wash. Scraps of old sheets or tablecloths are best 
used for handkerchiefs and burned afterward. 



CONTAGIOUS DISEASES 379 

A sheet should be hung from the top of the door frame out- 
side the door to lessen air communication with the rest of the 
house. 

After desquamation has begun general inunction of the skin 
is of service in preventing the dissemination of the scales. Plain 
vaseline is as good as anything as it is doubtful if any anti- 
septic of suiheient strength to be bactericidal will not be strong 
enough to cause an irritation of the skin; 2 per cent of carbolic 
acid can be added if there is much itching, but it must not be 
used very strong. 

Toys and books should be destroyed after the child has been 
removed from quarantine. 

The room should be carefully fumigated and the walls and 
woodwork wiped down with a 1/1000 solution of bichloride of 
mercury or 1/20 solution of carbolic acid. 

Symptomatic Treatment. As there is no specific for scarlet 
fever the treatment is largely symptomatic. 

Fever. For hyperpyrexia coal-tar products should not be 
used but hydrotherapy employed without any hesitation. The 
sponge bath or wet-sheet pack can be used without trouble, and 
in spite of remonstrance from the family. During the bath 
the circulation should be watched, especially of the hands and 
feet, and hot-water bags applied to them if they are persistently 
cold. A continuous temperature above 103.5° F. usually re- 
quires attention, but the effect of the temperature on the patient 
should be the guide. Gentle friction of the skin should be used 
Vv'hile the bath is being given. A little alcohol in the water for 
sponge bath is advantageous. It is well, with a tendency for 
the temperature to run high, to place an ice bag to the head, 
which usually materially assists in the control of the fever. 

Kidneys. Water should be given at very frequent intervals 
from the onset of the symptoms in order to keep the kidneys 
flushed. This is especially the case in the cases with severe 
angina when the mixed infection is apt to be a feature. The 
following is of benefit: 



380 THE DISEASES OF CHILDREN 

I^ Liq. ammonii acetatis §ss. 

Spiritus aetheris comp. § i 

Aquae destillat. q. s. §iv 

M. Sig. One teaspoonful every 3 hours. 

Bowels. If the vomiting is not persistent, an initial dose of 
calomel of 1 to 3 grains is of great benefit and should be given 
as soon as possible. If not effectual in obtaining a free evacu.a- 
tion it should be followed by 2 or 3 drachms of castor oil. Daily 
evacuations, which must be insisted upon, can probably be ob- 
tained by using an enema or glycerine suppository. An occa- 
sional drachm-dose of cascara aromatic, or syrup of tamarinds 
may be needed during the bed stage. 

Owing to the great amount of extra work thrown upon the 
kidneys, the diet should be such as will not increase elimination 
by the kidney, hence a milk diet is decidedly the best. A mixed 
diet, with no meat, can be begun after complete subsidence of 
the fever and rash. 

A very good rule to follow is to keep the child in bed for one 
week after the disappearance of the rash, and then to let it get 
out of bed for a gradually increasing time each day, being well 
protected from exposure if not entirely dressed. 

Nose, Throat and Ears. Antiseptic spray, DobelFs solution, 
normal salt and boracic acid solution in equal parts, warmed 
to 110° F., can be used as either a spray, douche or snuffed up 
the nose, in cases with profuse nasal discharge, or used as an 
irrigation in angina. The danger of forcing fluids through the 
Eustachian tube into the middle ear and causing an infection 
should be remembered. ^N'asal irrigation with fountain syringe 
is recommended in smaller children. 

Regular, four-hour interval irrigation of the middle ear when 
the drum has ruptured with warm boracic acid solution should 
be carefully done, the ear dried, and powdered boracic acid 
insufflated into the middle ear. Paracentesis of the drum should 
be done if an examination of it shows it to be bulging, in order 
to obtain free and prompt drainage. This should be done under 



CONTAGIOUS DISEASES 381 

a general anesthetic always, as the shock to the child from the 
pain and being held is too gTeat to have it done without. 

Soreness of the throat is a prominent symptom at the onset, 
and cold applications are very serviceable. A small, wet flannel 
is folded and placed next the throat and covered with a wider, 
dry piece of goods. Crushed ice fed to the patient is sometimes 
found to be grateful to the throat. The tendency to adenitis 
may be largely controlled by the cold, wet pack. 

For the nervousness and restlessness which is often a decided 
feature in the early stages of the eruption, the following can 
be safely used in a child of five years. 

I^ Strontii bromidi 5iii 

Chloralis 3iss 

Syr. limonis §i 

Aquee destillat. q. s. 5iii 

M. ft. sol. 
Sig. One teaspoonful every 3 hours as needed. 

Heart. The circulation should be watched closely. The ten- 
dency is to have a much-increased pulse rate and the first evi- 
dence of flagging in its quality should be met by the adminis- 
tration of strychnia, whisky and probably by digitalis. Digitalis 
can be given in the fat-free tincture, in 5 drop doses. If whisky 
is used, only an article of known value, or one which has been 
bottled in bond, should be used. Strychnia can be given in 
1/150 grain doses, and if used for sometime the child watched 
carefully for twitchings which may develop if it is used too long. 

During convalescence iron is indicated in some form, and if 
there is an indication of kidney involvement, Basham's mixture 
is serviceable, in -J to 1 teaspoonful doses, well diluted, three 
or four times a day. 

Severe adenitis is best treated by the application of ice 
cloths or an ice bag. ]^o virtue can be found in the so-called 
mud preparations, and only great discomfort is given the patient 
when they are applied. 

Too much emphasis cannot be laid upon the importance of 



382 THE DISEASES OP CHILDREN 

fresh air throughout the entire course of the disease. Protect 
the bed from draughts, plenty of coverings, and keep the win- 
dows open, an open fireplace is to be preferred greatly to a 
gas fire, closed stove or furnace heat. 

VAKICELIA. 

Synonym. Chicken-pox. 

Definition. A specific, infectious and contagious eruptive 
disease common to childhood. It is characterized by a rash 
which appears as a maculopapule, followed by a vesicle, the 
latter drying and falling off as an encrustation or scab. 

Etiology. The specific organism has not been isolated, but 
it is highly contagious and can be carried by a third person. 
It is contagious throughout the eruptive stage, and the scales 
being capable of transmitting it. Age is an important factor. 
It occurs chiefly in children under 10 years of age, being rarely 
seen in adults. 

Symptoms. Period of incubation, invasion or prodrome, 
eruption and desquamation. 

The incubation period is from 10 to 16 days, the average pe- 
riod being about 12 days. There are no symptoms common to 
this period. 

Invasion. There are few prodromal symptoms, in the major- 
ity of cases the rash being the first symptom. Frequently the 
child may be quite restless during the night and may itself 
call attention to the rash when dressing in the morning. There 
is apt to be a slight rise in temperature. Digestive disturbances 
are rare, though there may be vomiting. 

Eruption. The first spots noticed are usually upon the 
chest, and the margin of the hair and face. If seen early the 
rash will appear as a reddish blotch, followed soon by a papule, 
upon the apex of this appearing a tiny vesicle which gradually 
enlarges in size. The rash rapidly spreads to other parts of the 
body, appearing in successive crops for 48 hours, so that at the 
end of this period there are present all stages of the eruption 



CONTAGIOUS DISEASES 383 

at the same time. The papule usually is about one-fourth of 
an inch in diameter, the vesicle being slightly smaller, having 
the appearance of resting upon a red base. Occasionally the 
vesicle will develop upon the skin without the primary macule 
or papule, looking like a drop of water on the skin. The fluid 
of the vesicle at first is clear, but in a few hours it is cloudy in 
color. The vesicle is unilocular and when pricked upon the top 
the fluid escapes. As the vesicle dries the scab forms. Some- 
times the vesicle becomes infected and a good deal of cellular 
infiltration may occur, with ulceration into the true skin, and 
resulting pitting scar. Coincident with the appearance of the 
exanthem, the enanthem appears on the mucous surfaces, the 
mouth, vulva and prepuce. 

The eruptive stage lasts from three to four days, when all 
the spots are usually scabbed over, the scabs becoming separated 
in from two to three weeks. 

Systemic Symptoms. The temperature rises, though it is ex- 
ceptional to find it very high. It does not run a regular course, 
and is rarely over 102.5° to 103° F. During the fever the 
papular and vesicular stages, the child is restless and peevish, 
complains frequently of itching and burning, and the tempta- 
tion to scratch is very great. No digestive disturbances are 
seen, as a rule, unless there is the initial vomiting, which does 
not recur. 

Desquamation slowly proceeds during the last two weeks of 
the disease, a few scales dropping off from day to day, usually 
leaving a dry base, lighter in color than the surrounding skin. 
Sometimes there is a decided ulceration, in case the vesicle 
has been infected. 

Complications and Sequelae. The only complication of moment 
I have ever seen was an erysipelas, which was very severe and 
extensive, and which proved fatal. 

Varicella gangrenosa has been reported as a complication. 
This is extremely severe and usually fatal. Ulceration at the 
site of one or more of the vesicles may take place, extending into 



384 THE DISEASES OF CHILDREN 

the true skin, and these always leave a pitting scar. It is quite 
usual to find one or more of these pits somewhere upon the body. 

Hemorrhage may rarely occur in the vesicles. Second at- 
tacks are practically never seen. 

Diagnosis. The chief disease to be diagnosed from is small- 
pox of a mild type. Corlett gives the following diagnostic 
points: {a) Varicella has very mild prodromal symptoms, and 
they may be absent altogether, {h) The eruption appears on 
the trunk, where it is more abundant than on the face and 
hands, (c) The multiform character of the eruption, its super- 
ficial position, comparable to drops of water sprinkled over the 
skin, and its appearance on the same region in successive crops. 
{d) Its mild constitutional symptoms and short duration, the 
disease usually terminating in 5 to 14 days, (e) It is mildly 
infectious and always gives rise to the same disease. 

Prognosis. In uncomplicated cases is always good. 

Treatment. Isolation is the principal consideration. Con- 
finement to bed is necessary only during the febrile stage. If 
the child is old enough it should be warned against scratching, 
if too young its hands should be covered in order to prevent it. 
A 2 per cent carbolic acid vaseline ointment will prevent itching 
and make the patient more comfortable. The bowels and diges- 
tion must be watched and daily baths given. 

VACCINIA. 

Synonym. Cowpox. 

Definition. This is an eruptive disease in the human race 
caused by the introduction into the system of the small-pox 
virus or lymph, obtained from one of the vesicles. 

History. Edw. Jenner, in May, 1796, after observation of 
cases of cowpox in milkers and the immunity it gave those con- 
tracting it, performed the first vaccination on the human subject. 
The first vaccination in America was performed in 1800 in 
Cambridge, Mass. Statistics prove what a boon to humanity 
has been the discovery of vaccination. 



CONTAGIOUS DISEASES 385 

Technic. A child should be vaccinated before the end of its 
first jear, and revaccinated at the end of every seven years. 
Statistics have shown that in cases of small-pox occurring in 
persons giving a history of a successful vaccination, the vac- 
cination was done more than seven years previously. 

Vaccination should not be done in a child who is actuely ill 
or who has a skin lesion, or in a child suffering from any of the 
diseases of malnutrition. The occurrence of an epidemic of 
small-pox is the only reason for not making these exceptions. 

The site of the vaccination has been the subject of much 
comment, whether it should be done upon the leg or the arm. 
Owing to the possibility of an infection occurring after the 
operation and the greater number and size of the inguinal 
lymphatics, the choice of the arm should always be made. The 
point of selection is just above the insertion of the deltoid 
muscle. 

The selection of the virus should be made with care: The 
scab from a vaccination scar should never be used because of 
the danger of infection. Only bovine lymph should be em- 
ployed and the glycerinated lymph is best, as this form of 
lymph is sterile and there is no chance for it to become con- 
taminated with bacteria. The glycerinated lymph is furnished 
by reliable firms in sealed capillary tubes and in hermetically- 
sealed tubes containing glass or ivory points, upon which is 
smeared the virus. 

The operation should be considered strictly a surgical pro- 
cedure and performed with great care and in a surgically, 
cleanly manner. The arm is bared, washed with soap and water, 
and dried, but no antiseptics should be used. The skin should 
be scarified over an area one-half inch square, and the lymph 
rubbed into this and allowed to dry. A sterile, medium-size, 
cambric needle can be used for the scarification, care being 
taken not to make the scratch deep enough to draw blood, or 
the end of the point can be used to rub off the upper skin. It 
usually takes 15 or 20 minutes for the lymph to dry. To facil- 



386 THE DISEASES OF CHILDREN 

itate the child's having its sleeve pulled down, cut a piece of 
light cardboard, round, l-J to 2 inches in diameter, and then cut 
it half through. The cut edges are slipped bj each other and 
a cone formed. This is held in place by narrow strips of ad- 
hesive plaster. When the lymph is dry the improvised cone 
shield can be removed. 

The after-care of the vaccination area should be mentioned. 
Bad results are due to infection transmitted to the wound after 
the vaccination has been performed, and not to a contaminated 
virus, provided the virus from a reliable maker has been selected. 
After the wound has dried it usually needs no attention or pro- 
tective dressing, unless it be one or two layers of gauze bandage. 
A typical vaccination will run its course without breaking 
down or becoming moist. If it does become moist and the 
sleeve sticks to it a shield which is perforated, has a wide base 
to rest upon the arm, and large enough to make no pressure on 
the vesicle, should be applied as a protection. If the wound 
becomes infected with pus formation it should be treated sur- 
gically as other wounds. 

Vaccination History. Upon the third or fourth day follow- 
ing a successful vaccination, the area scarified becomes red, 
and slightly indurated and raised. Upon this area, on the next 
or second day following a vesicle, slightly smaller than the red 
area forms, which is decidedly umbilicated. The reddened area 
spreads to half an inch or more in width, with perhaps a con- 
gested area, much lighter in color, extending 2 or 3 inches or 
encircling the entire arm. The vesicle at first is pearly white, 
gradually changing in color to a yellow or brownish color, and 
then drying up, if normal, without rupture. A distinct scab 
forms which gradually loosens, leaving a dry scar, slightly de- 
pressed, and containing a number of smaller depressions or pits. 

The time usually required for a '^take" is as follows : Fourth 
day, indurated red area or papule; sixth day, vesicle; tenth 
day, pustule ; twelfth day, scab ; fifteenth to eighteenth day, 
scab separates, leaving the scar. 



CONTAGIOUS DISEASES 387 

Symptoms. Coincident with the formation of the vesicle there 
may be a rise of temperature from 3° to 5°, 101° to 103° F., 
and may last until the formation of the scab. The arm feels 
swollen and stiff, and there may be some glandular enlargement 
in the axilla, and pain. Around the vaccination area several 
small pustules may form which are superficial and leave no 
scars. 

Complications. The chief complications which occur are those 
referable to the skin, and the most striking is a general vaccmia. 

This is an eruption which is like that seen in some cases (and 
referred to above) occurring around the site of the vaccination, 
pustular in character, appearing about the tenth day, and if 
closely watched passing through the papular, vesicular and 
pustular stages. 

A general erythematous eruption is more frequently seen, 
resembling a measles eruption. This may occur only on the 
trunk or around the waist, buttocJ^:s and thighs. It is hot, 
slightly raised and itches a good deal, and usually is of short 
duration, lasting from a few hours to two or three days. 

An urticaria, similar to that complicating the injecting of 
any of the sera subcutaneously, may occur. 

A cellulitis about the vaccination area is a common occur- 
rence. The entire arm may be involved, it is greatly swollen, 
very tense and painful, the arm is very "sore." In these cases 
the vesicle is apt to rupture, and the whole area occupied by the 
vesicle may become gangrenous. 

In the colored race, especially, and frequently in the white, 
a keloid forms in the scar tissues left after the separation of 
the scab, which may become raised above the surface of the 
skin, and is firm and glazed. 

The distinctness of the vaccination scar is not sufiicient evi- 
dence of the persistence of immunity conferred by a single vac- 
cination. It is frequently found that a typical "take'' is re- 
corded in a person with an excellent and tvpical mark if more 
than seven years have elapsed since the first vaccination. 



388 THE DISEASES OP CHILDREN 

A natural immunity does not exist. If a primary "take" 
has not been obtained there has been some fault in the technic, 
and the operation should be repeated until successful. I have 
myself revaccinated until on the fifth attempt a successful '^take'^ 
was obtained. 

VARIOLA. 

Synonym. Small-pox. 

Definition. The most contagious of the exanthemata char- 
acterized by a sudden onset, high fever, a rash, going through 
regular stages of development, viz., papule, vesicle, pustule, 
scab and desquamation. If one unprotected by vaccination is 
exposed to the contagion he is practically always attacked. 

Etiology. It is believed by Councilman and others that the 
organism, the cause of small-pox, has been isolated, though it 
has not been cultivated on artificial media. These bodies are 
described as occurring "in epithelial cells, in the nuclei and 
free." 

The disease is contracted by direct contact and the contagion 
can be carried upon the clothing, etc. The most virulent car- 
rying medium is the pus from the pustules, and the scabs which 
later form, and the excreta. The organism gains entrance to 
the body through the mucous membrane. The contagion can be 
carried through the medium of the air. It is contagious from 
the first symptom until desquamation is complete. 

Segregation in cold weather increases the frequency of small- 
pox. 

Symptoms. Several types are recognized, variola vera, which 
may be confluent or discrete ; hemorrhagic , varioloid or modified 
form. 

The ordinary form has the following periods, invasion, incu- 
bation, eruption and desquamation. 

Invasion. According to different observers the stage of inva- 
sion lasts from 8 to 20 days, the average being probably 15 days. 
There are no symptoms to this stage. 



CONTAGIOUS DISEASES 389 

Incubation. The symptoms of this stage vaTj according to 
the age of the patient. In the yonng it is frequently ushered 
in by a convulsion, nausea and vomiting. In the adult, there 
may be a chill, instead of the convulsion. There is regularly 
a rapid rise in temperature, usually reaching 104° F., without 
much variation, severe headache and pain in the back in the 
region of the loins. This pain is perhaps the most prominent 
symptom. The bowels may be disturbed, but not regularly so. 

Eruption. On the third day, sometimes on the second, a 
macular eruption appears on the forehead, face, wrists and 
forearms, and neck, which by the fourth day is decidedly papu- 
lar. The first day they may be difficult to diag-nose. It quickly 
spreads to the rest of the body. On the summit of the papules 
vesicles form about the fifth day, which gradually change to 
pustules by the tenth day, and by the fourteenth day these have 
become encrusted, with a shedding of some of the crusts. The 
desquamation proceeds in the order of the appearance of the 
rash. 

An enanthem forms coincidently with the exanthem. 

The vesicles have a decided umbilication or depression, which 
remain until the pustules form. After the scabs fall off the 
skin is left slightly discolored, and according to the depth of the 
ulceration a pit or depressed scar remains. There may be a 
coalescence of the pustules on the face, or they may rupture, the 
pus drying upon the skin forming a crust over the entire face. 

The fever runs a fairly typical course, sudden of onset, reach- 
ing 104° or even 106° F. the first day, and remaining up until 
the eruption appears, when it gradually recedes to normal or 
very slightly above, about the fifth day. It remains down then 
until the pustules are formed, about the tenth day, when it 
reaches usually the height it was at first, or even higher. 

Fever persists during the pustular stage, gradually falling 
to normal during the latter part of the third week. 

Coincident with the first drop in the temperature the general 



390 THE DISEASES OF CHILDREN 

symptoms abate, the restlessness, backachej headache, etc., 
improve. 

During the septic temperature there is a return of these symp- 
toms to a certain extent, and they may be very severe. Absorp- 
tion may be enough to cause septic symptoms of gravity, the 
patient being drowsy or even delirious. 

In the confluent variety all of the symptoms are more severe. 

Hemorrhagic Variola. This form is the most severe. There 
is an extravasation of blood in the vesicles, either as a primary 
lesion or the blood appearing during the pustular stage. 

Varioloid. This is a modified form of small-pox occurring in 
individuals in whom the immunity from a previous vaccination 
has about disappeared, and is as contagious as variola, true 
small-pox being caused by it. In varioloid there is very little 
eruption and no secondary fever, all of the symptoms being 
very much less severe, and of shorter duration. 

Complications. These are few, as a rule. The pustules may 
cause deep ulceration and consequent pitting and permanent 
scarring of the shin. 

There may be a catarrhal or purulent inflammation of the 
middle ear. The eyes may be involved, an ulceration of the 
cornea being sometimes found. A laryngitis is not infrequent, 
and an extension downward causing a bronchopneumonia may 
occur. Furunculosis and adenitis occasionally occur during the 
convalescence. 

Diagnosis. Until the appearance of the rash the diagnosis 
cannot be positively made, but when a sudden high temperature 
is seen with severe headache and backache, in the absence of an 
epidemic of grippe, small-pox should be suspected. The most 
frequent disease with which it is confused is chicken-pox. The 
great infrequency of chicken-pox occurring .in adults should 
cause variola to be suspected in every vesicular eruption. The 
discrete eruption in varioloid and the mildness of the general 
symptoms are deceptive. 

Prognosis. Vaccination and age influence the prognosis 



CONTAGIOUS DISEASES 391 

greatly. The mortality in late epidemics lias been very light. 
In the unvaccinated young the prognosis is grave, always. The 
extent of the rash upon the face is a good guide as to the severity 
of the attack. The occurrence of hemorrhages is a bad outlook. 

Treatment. Prophylaxis. Vaccination, isolation and disin- 
fection are the best methods of prevention. It is absolute by 
vaccination, the immunity thus convej-ed lasting in its fullest 
from ^ye to seven years. Revaccination should be practiced. 

'No city is safe from epidemics without the erection of an 
isolation hospital, removed beyond the city limits. The care 
of these cases should be left to the city authorities, and prompt 
report of cases in the city made to the Health Board should be 
required. 

Disinfection should be most thorough, the formaldehyd, per- 
manganate of potash method being very efficient. Bedding- 
should be destroyed and the room thoroughly overhauled and 
cleaned. Vaccination of every person known to have been 
exposed to a case of small-pox should be insisted upon, and its 
spread thus limited or stopped entirely. 

Local. The confinement of the patient in a room in which 
only red rays of light are admitted has been shown to be 
efficient in limiting the inflammatory reaction in the pustules, 
and consequent limiting of the amount of pitting or scarring. 

The pain and burning in the skin from the eruption is best 
relieved by the local application of soothing, antiseptic lotions 
upon a mask cut from gauze. The following is of benefit: 

I^ Acidi carbolici puri liquefacti oiss 
Zinci oxidi pulv. 5i 

Aquae deslillat SB q. s. oiv 

M. ft. sol. 

Sig. Saturate cloths and apply to face or other parts, 
at frequent intervals, 
or 



I^ Ichthyolammon. sulph. 


5vi 


Aquae destillat. 


Siv 


M. ft. sol. 




Sig: Locally. 





392 THE DISEASES OF CHILDKEN 

In the pustular stage the following is recommended: 

IJi Acidi carbolici njjxv 

Aq. calcis 

01. Olivse aa § ss 

M. Sig. Locally. 

In the event of eye involvement, pus exuding from the con- 
junctival sac, and danger to the cornea from ulceration being 
present, thej should be frequently irrigated with boracic acid 
solution, and an occasional drop of atropia solution introduced. 

Fever is best combated, both primary and secondary, by 
hydrotherapy, sponge bath, wet pack or tub bath. The use of 
baths during desquamation, followed by oil rubs, hastens this 
stage. The patient should be kept strictly in bed during the 
entire eruptive stage. 

For the great pain during the stage of incubation, in the 
back and head an opiate may be necessary. The coal-tar deriva- 
tives should be used with great caution. 

Stimulation may be needed at certain stages, whisky, digitalis 
or strychnia. 

The diet should be fluid, preferably milk, and broths with 
plenty of water. 

Bromide and chloral can be used for the great restlessness. 

PERTUSSIS. 

Synonym. Whooping-cough. 

Etiology. This is unquestionably due to a specific infectious 
organism, but as yet it has not been isolated. Its habitat is the 
nose and throat, and is directly transmitted from one child to 
another. An influenza-like bacillus has been found by many 
observers. It is minute and hemophilous. It is not necessary 
for the infecting child to cough to transmit the infection, as it 
can be carried through the air from ordinary breathing, but 
the children must be fairly close together, and also by toys, 
clothing, etc. It is both endemic and epidemic. It is con- 
tagious at any time in its course. I^o age is exempt, though 



CONTAGIOUS DISEASES 393 

it is much more common between the ages of one and ten years, 
the majority of cases occur under three years old. The young- 
est child I have seen with it was six weeks old, the attack proving 
fatal. Cases much younger have been reported. One attack 
does not confer immunity in every case. My oldest child had 
two distinct attacks. I have seen one grandfather over 60 years 
of age with a severe attack. 

Pathology. There is a catarrhal condition of the mucous 
membrane of the nose, pharynx and larynx, and especially the 
trachea, with very frequent involvement of the bronchi as a 
complication. In severe cases there may be a true or a com- 
pensatory emphysema. 

Symptoms. The incubation is generally about two weeks. 
There is a cough which shows no tendency to improve, and in 
spite of ordinary remedies grows more persistent, and without 
signs in the chest to account for it. This is usually described 
as the catarrhal stage, and lasts from one to two Aveeks before the 
spasmodic or whooping stage is reached. In the catarrhal stage 
there may be a slight puffing of the lower eyelids, some loss of 
appetite and disinclination to play, as exertion tends to increase 
the cough. During the last of this stage the cough becomes 
more paroxysmal in character, the child going some time between 
the paroxysms without coughing. The paroxysms become spas- 
modic, they begin with a slight, hacking cough, Avhich gradually 
becomes more severe, and ends in a long-drawn, deep inspiration 
accompanied by a crowing sound, which is the characteristic 
^Vhoop" from which the disease took its name. Once heard, 
there is no mistaking the sound. The child loses its breath for 
a moment and gets very red or dark red in the face, the eyes 
and nose run ; the child runs to some one or grasps a fixed object 
for support, and with the last deep inspiration and whoop, may 
vomit the contents of the stomach, and mucus from the trachea. 
After the paroxysm is over the child falls back exhausted, its 
color gradually returns, and it may shortly resume its play. If 
the paroxysms are repeated very frequently there may be a 



394 THE DISEASES OF CHILDREN 

deep injection of the superficial vessels in tlie conjunctiva or a 
subconjunctival hemorrhage. Between paroxysms the child's 
face is puffy and bloated about the eyes, due to lymphatic stasis. 
There may be an ulcer under the tongue in children with lower 
teeth. 

Paroxysms are brought on by severe exercise, eating, often a 
drink of water, excitement, and usually recur every half hour 
to an hour in the 24, but there are often many more than this. 
If a count can be kept of the number of the paroxysms, day 
and night, the effect of medicinal treatment can best be noted, 
as that would be the first improvement. 

After about two weeks, or more, of the severe paroxysms their 
frequency and severity both become less, and in this period of 
decline, the child shows a general improvement. It does not 
vomit now with each paroxysm and sleeps longer at night. 

During this stage, if the child acquires a fresh "cold," its 
cough partakes of the same paroxysmal nature, and, in fact, for 
some weeks afterward. 

Churchill* and others have made investigations as to the 
differential blood count during whooping-cough. Comparing 
the lymphocyte count in whooping-cough with the normal count 
of a child at 10 years, which will average 32 per cent, in whoop- 
ing-cough it will run from 34 per cent to 93 per cent. 

Mosenthalf found in "institutional" children the average 
leucocyte count to be 13,850 to 16,391. The percentage of 
polymorphonuclear cells is slightly diminished with a corre- 
sponding increase in the mononuclears. 

During the catarrhal stage of pertussis, an increase in leu- 
cocytes is found, approximating double the normal, and the 
mononuclear cells increased about 5.5 per cent. 

A hyperleucocytosis, with an increase in the percentage of 
mononuclear cells at the expense of the polymorphonuclear, is 
an aid to the diagnosis of pertussis in the catarrhal stage. 

* Journal American Medical Association, 1906, volume xlvi, 1506-9. 
t Archives Pediatrics, Novem.ber, 1908. 



CONTAGIOUS DISEASES 395 

Complications. The most frequent is a bronchitis ^ thoiigli a 
bronchopneumonia is often seen. An emphysema may occur in 
very severe cases, v^hich is more or less permanent. From the 
passive congestion, due to bronchial involvement, there are apt 
to be hemorrhages from the nose and into the conjunctiva and 
brain. Hernia may result from the straining at coughing, and 
the rectum may also be forced out in young children. Incon- 
tinence of urine during coughing is not infrequent. The simul- 
taneous occurrence of measles and pertussis has been often 
reported. Tuberculosis may have its starting point in an attack 
of pertussis. 

Diagnosis is not at all certain, and is most often made by the 
mother and nurse before seen by the physician. A history 
of exposure, and paroxysmal coughing, even without the whoop, 
is sufficient for a diagnosis. In an epidemic one may see severe 
paroxysmal coughs and absolutely no tendency to whoop. The 
diagnosis must be made from tubercular bronchial glands, hyper- 
trophied tonsils and chronic bronchitis. 

Prognosis. Id very young children the prognosis is always 
grave because of the lack of nourishment, the physical exhaus- 
tion due to the coughing, the tendency to the occurrence of com- 
plications. Too little attention is paid to whooping-cough, as a 
rule, and there are too many wanton and willful exposures to 
it, "that the child may have it while it is young," for many a 
child dying of pneumonia had whooping-cough as the chief 
factor in the fatality. The more frequent the paroxysms and 
the vomiting, the graver the prognosis. The beginning of an 
epidemic in institutions is greatly to be feared. In the 1902 
census whooping-cough ranked fourth as a cause of death. In 
1906 it caused more deaths than measles or scarlet fever. 

Treatment. Quarantine of the affected child should always 
be insisted upon, and municipal control of the quarantine should 
be possible. The diet should be in small amounts, and prin- 
cipally of milk, especially if vomiting is a prominent symptom. 



396 THE DISEASES OF CHILDREN 

It may be necessary to peptonize the milk, or to give one of the 
predigested foods. 

Fresh air is most essential and the more these children are 
out of doors the better. The room temperature should range 
between 55° and 60° F. The tendency to bronchitis must be 
remembered and the child perfectly protected. 

Local and Medicinal. A great number of drugs have been 
recommended for pertussis, but none can be relied upon. A 
much-vaunted remedy is the vaporizing with a lamp of one of 
the phenol preparations. This has been reported of service by 
some, but is a dangerous remedy as carbolic acid poisoning is 
a possibility. The room full of fresh air is decidedly the better 
of the two remedies. 

Internally several remedies are used more regularly than 
others, viz., antipyrine, bromide, quinine, codeine, belladonna 
and bromoform. 

Antipyrine can be used in doses of 1 grain to each year of 
the age, up to 3 grains every two hours, with syrup of tolu as 
a vehicle. Quinine can be added to this prescription or given 
alone, up to 3 grains at a dose, or with glycyrrhiza or yerba 
santa. Bromide can always be given with either of these 
mentioned. 

Codeine is a valuable assistant to any of the above, and can 
be given for its effect. 

Belladonna is probably best given in the form of the fluid 
extract (-J min.) or tincture (2 min.) doses, and it must be 
given for its physiological effect. 

Bromoform is a dangerous drug, because of the difficulty of 
forming a perfect mixture, and the invariable settling of por- 
tions of it to the bottom, and the last two or three doses con- 
taining perhaps a lethal dose of the drug. I have seen three 
children put to sleep for many hours by being given the last 
three doses in the bottle. 

Sior* recommends the use of euchinin as a substitute for 

* Jahrb. fiir Kinderhk., 1908, p. 452. 



CONTAGIOUS DISEASES 397 

quinine in tlie treatment of whooping-cough. It is recommended 
in doses of a centigram for each month, and a decigram for 
each year, twice a day, morning and night, given in sugar, 
milk or cold chocolate. It can also be given in suppositories. 
The report of the cases in which it was used showed a cessation 
of vomiting, disappearance of cyanosis and a shortening of the 
duration. 

Dr. T. W. Kilmer has reported a number of cases materially 
benefited and the attack shortened by the wearing of an abdom- 
inal binder, made of linen with a strip of elastic webbing under 
each arm and lacing up the back. He claims for it that the 
paroxysms are reduced in severity and number, vomiting 
relieved and complications less frequent. 

After the child has ceased coughing it should be given a 
tonic, which will make up the leucocytosis and low hemoglobin 
which is nearly always present. 

PAROTITIS. 

Synonyms. Mumps, parotiditis. 

Etiology. The infecting organism is not known. It is very 
contagious, occurs epidemically as well as in endemics; affects 
children more often than adults, and chiefly between one and 
five years of age. The contagion is taken into the system through 
the respiratory organs, and from close contact. Immunity is 
conferred by one attack. 

Symptoms. The incubation period may be as long as three 
weeks, though it is usually much shorter. There are, as a rule, 
one or two days of lassitude, headache, anorexia, perhaps nausea 
and vomiting. The temperature usually reaches 101° to 103° 
F., and is at its height with the enlargement of the parotid 
gland. The parotids usually enlarge by the fourth day, assum- 
ing large proportions. The child complains of pain or soreness 
on swallowing, stiffness at the angle of the jaw, and after eating 
the glands usually feel very tense. Acids usually cause great 
pain on swallowing. 



398 THE DISEASES OP CHILDREN 

The swelling primarily may not be very great, and is located 
directly under the lobe of the ear. It gradually increases in 
size. After about 10 days the swelling subsides, the stiffness 
in the jaws and the pain on swallowing disappear. 

Complications. A coincident involvement of the submaxillary 
glands may occur, and there may be a metastasis in the testicles 
or ovaries. In males there is pain in the scrotum, with rise in 
temperature, probably preceded by a chill. The epididymis 
becomes enlarged and tender, and there may be an involvement 
of the testicle also. With an ovaritis in the female there may 
be pain and enlargement of the breasts. 

Prognosis. Barring complications the prognosis is uniformly 
good. 

Treatment. Isolation and protection from exposure are the 
chief indications. The application of heat to the enlarged gland 
is of service in relieving pain. The glands should be covered 
by a piece of dry flannel by carrying the bandage under the 
chin and over the ears, and pinning on the top of the head. 

The diet should be liquid as chewing is usually painful. The 
mouth should be cleansed, and if an orchitis develops the testicle 
should be supported by hammock-like arrangement made by 
folded towel or a suspensory. Guaiacol in 25 per cent ointment 
has been found serviceable in many cases of epididymitis, giving 
great relief from swelling and pain. 

LA GKIPPE. 

Synonyms. Influenza, grip. 

Etiology. This is due to the invasion of the bacillus known 
as Pfeiffer's bacillus. It is short and small, and is found in the 
secretions from the nose and respiratory tract. It grows on 
various media to which blood has been added. It stains with 
a carbolfuchsin, 10 per cent solution. They appear either in 
masses or threads of short, thick rods. They are found in the 
pus cells which are present in the nasal secretions later in the 
disease, and at this time the streptococci and staphylococci are 



CONTAGIOUS DISEASES 399 

associated with the Pfeilfer bacillus. It gains entrance through 
the respiratory mucous membrane. 

Epidemics of grip have been described for years and they 
sweep over the whole country at intervals. It attacks both 
adults and children, but without regularity. More children 
seem affected in some epidemics than adults. It may occur at 
any age, and' is readily communicable from one person to 
another. Some persons are specially susceptible, having recur- 
rences both during the same and different epidemics. 

Pathology. There is no distinct pathology due to the bacillus 
itself, the pathological changes being chiefly due to the bacteria 
usually found with it. These changes are chiefly a catarrhal 
condition of the respiratory mucous membrane. There may 
be a general enlargement of the lymph nodes and of the spleen. 

Symptoms. Several types are encountered in an epidemic, the 
chief symptoms being referred to the respiratory organs, the 
muscular system, the nervous system or the gastroenteric tract. 

In all forms there is apt to be the initial chill, followed by 
fever up to 103° or 104° F. Tha period of invasion is short 
and generally without special symptoms, not more than a week 
and the incubation a day or so, during which time there is 
usually a dull headache, loss of appetite and irritability. 

In the respiratory form there are signs of a cold in the head, 
sneezing, suffusion of the eyes and swelling of the nasal mucous 
membrane. This is followed by a cough and expectoration, with 
probably pain in the chest. The physical signs are those either 
of a bronchitis or a bronchopneumonia, according to the involve- 
ment. The occurrence of pain on inspiration, hurried respira- 
tion and pulse, in the pneumonic ratio, and a rise in temperature 
is usually enough to complete the diagnosis. Usually there is 
more or less muscular aching in this variety also. The bacilli 
can be found in the nasal secretions. In the muscular form, 
foUow^ing the chill and initial vomiting, there is headache and 
pain in the back, joints and muscles of the arms and legs. The 



400 THE DISEASES O^ CHILDKEN 

child cries when handled and prefers to lie in its bed. The 
fever is quite high, and the pulse accelerated. 

In the nervous form there may be convulsions in the very 
young, with severe headache when the child is able and old 
enough to complain; there is photophobia, great restlessness, 
irritability and nervousness. The prostration is severe and con- 
valescence more prolonged in this type. 

The gastroenteric form is seen in the younger patients. 

Vomiting is always present, the bowels being also upset with 
thin, green and mucous stools at frequent intervals. There is 
anorexia and coated tongue, with tympany, restlessness and 
fever. 

Complications. The chief complications are the inflamma- 
tions of the respiratory tract found in all of the varieties. These 
may be caused by the influenza bacillus alone, but usually there 
are associated the pyogenic cocci as well. 

One of the most frequent complications is an involvement of 
the sinuses contiguous to the nares and the ear. Frontal sinus 
inflammation, middle-ear inflammations and mastoiditis are 
very frequent. During the last epidemic in this section of the 
country these complications w^ere of very frequent occurrence. 

Malnutrition and athrepsia may follow acute grip in younger 
children. Synovitis may occasionally be seen as a complication. 

Prognosis. Uncomplicated, the prognosis is good; with a 
pneumonia it is more or less grave. Severe gastrointestinal com- 
plications are diflicult to recuperate from. Convulsions make 
the prognosis less favorable. 

Treatment. Isolation of cases of grippe is most important. 
Keep the patient strictly in bed, giving easily digested and 
nutritious food. Milk, diluted, is the best all-around food, 
except in the gastrointestinal type, in which the cereal gruels 
and broths are best. 

An initial dose of calomel, followed by oil, is of great benefit. 

The coal-tar products should be given with the greatest cau- 



CONTAGIOUS DISEASES 401 

tion, and never without one of the diffusible heart tonics is 
given with it, as caffeine, camphor or strychnia. 

The salicylates have the best reputation as affording relief 
and can be given in any form, perhaps best in the form of 
aspirin, in 1 to 3 grain doses to child of two years. 

Quinine to older children can be combined with the aspirin 
in capsule or yerba santa as a vehicle. Vigorous stimulation 
may be needed and, of course, when needed it is urgent. 

In no other condition perhaps is a tonic treatment so indi- 
cated as in the convalescence from grippe, and especially in the 
respiratory and gastrointestinal forms, cod liver oil in some 
shape is of the greatest benefit. 

DIPHTHERIA. 

This is an acute infectious and transmissible disease, char- 
acterized by the deposit of a false membrane, caused by the 
action of a specific organism, the Klebs-Loeffler bacillus. The 
membrane may develop on any mucous membrane or on a 
denuded area on the skin. It is primarily a local disease, and 
the severe general symptoms and the complications are due to 
the toxins formed by the bacilli. 

Etiology. Diphtheria is caused by the Klebs-Loeffler bacillus. 
In the majority of cases the source of the infection cannot be 
traced. It may be endemic or epidemic. Milk, toys, cats, feed- 
ing utensils, books, clothing, linen, etc., may carry the bacillus. 
1^0 race or people is more prone to develop diphtheria than 
another. Infants under six months are rarely affected, and 
adults are much less susceptible. It is most frequent between 
one and ten years of age, perhaps the most cases during. this 
period occurring between three and -Q.Ye years. 

The most potent predisposing cause is the condition of the 
nose and throat, accompanying adenoids, chronically enlarged 
tonsils and chronic nasal catarrh. Any condition of the gen- 
eral system which lowers the resistance will act as a predis- 



402 THE DISEASES OF CHILDREN 

posing cause, as la grippe, bronchitis or other pulmonary 
diseases. 

Bacteriology, j^o attempt will be made to give an exhaustive 
description of the Klebs-Loeffler bacillus, the reader being 
referred to special works on bacteriology for that. It is of 
interest to note that it was not until 1883 that Klebs first 
described a bacillus constantly found in throats of patients dying 
of diphtheria, and a year later when Loeffler obtained the 
bacillus in pure culture and gave his knowledge to the world. 

The bacillus is aerobic, but grown also without oxygen, and 
grows best on serum media. It is rod shaped, straight or 
slightly curved. Usually wdth clubbed ends, varying greatly 
in its measurements. It stains with ordinary aniline dyes, the 
most satisfactory perhaps being Loeffler's methylene-blue stain. 

In bright sunlight the bacillus will not long survive, but it 
does live for a long time in the dark, in the mouth, and on toys, 
etc. Disinfectants have a very speedy effect. It is killed at 
(70° C, 136° F.) with ^ve minutes' exposure. 

AVhen other bacilli are present in diphtheria bacillus it is 
called a mixed infection. The most frequently associated forms 
of bacteria found are the streptococcus, staphylococcus, pneu- 
mococcus. It has been shown that the primary invasion is not 
infrequently with the streptococcus, the diphtheria bacillus 
being engrafted upon the soil prepared for it. 

The streptococcus is most frequently the cause of some of the 
complications met with in diphtheria, chief of which is broncho- 
pneumonia. 

The Membrane. Membrane may appear upon the mucous 
membranes of the nose and throat due to other organisms than 
the Klebs-Loeffler bacillus. The characteristic diphtheria exu- 
date is of a grayish-white color, and is firmly attached to the 
underlying mucous membrane. When it is removed it leaves 
a bleeding area beneath. There is^ a swelling of the membrane 
surrounding due to an edema. 

The development of an exudate on the tonsil alone may be a 



CONTAGIOUS DISEASES 403 

simple follicular tonsillitis, and when no history of exposure 
is given it may be difficult to make a positive diagnosis, but the 
appearance of a membrane upon the mucous membrane of the 
nose, nasopharynx or uvula, is very suspicious of a true 
diphtheria. 

Cultures from this membrane will clear up a diagnosis, and 
this may often be necessary. 

Bacteriological Diagnosis. Sterile blood serum is best used 
for the first growth. A culture is obtained from the throat by a 
probe, the end of which is wound with sterile absorbent cotton. 
This is rubbed over the membrane, being careful not to touch 
any other part of the throat or tongue. The child is held with 
face in good light, and tongue held down with depressor. The 
inoculated swab is then rubbed over the surface of the blood 
serum without breaking its surface. 

This tube is incubated at a temperature of 37° C. for 12 
hours. Experts can differentiate at the end of five hours, with 
a platinum needle a number of the colonies are scraped off the 
culture medium, some of this is washed off on to a cover glass 
with a drop of water. The cover is air-dried, passed three times 
through a fiame, stained with an alkaline methylene-blue solu- 
tion (Loeffler's) for 10 minutes, cold. It is then rinsed, dried 
and mounted in balsam. It is examined with a 1/12 oil-immer- 
sion lens. The diphtheria bacilli may be found in great num- 
bers, or a few with a preponderance of streptococci in chains. 

Direct examination of the exudate is uncertain and unsat- 
isfactory. 

Virulent bacilli have been found in healthy throats, and 
numerous observations have been made which show they persist 
in throats for a long period of time after the disappearance 
of the exudate. Park* reports one case in which they were 
found, eight months after the disappearance of the membrane. 
A pseudobacillus less virulent is sometimes found in the throat, 

* Park: Pathogenic Bacteria and Protozoa. 



404 THE DISEASES OF CHILDREN 

but it is believed these have been derived from the virulent 
forms. 

The bacilli generate a poison or toxin, and this can be 
obtained from cultures of living bacilli, by filtration through 
porcelain. 

An artificial immunity can be produced in the economy by 
the introduction of an antitoxin, a substance which will act as 
an antidote to the toxin. Natural immunity more or less active 
may exist in the human being. The blood serum of a person 
convalescent from diphtheria contains this antitoxin, but it dis- 
appears after a few weeks. 

Diphtheria antitoxin* is obtained by first growing a virulent 
culture of bacilli, sterilizing them by adding carbolic acid solu- 
tion. The solution is siphoned off, leaving the bacilli at the 
bottom. If 0.005 cc, when injected into a guinea-pig, will kill 
it promptly it is of the correct strength; 250 grains weight of 
this solution, or enough to kill 5000 guinea-pigs, is injected 
into a horse, and this is repeated every three to -^ve days, or 
until the fever reaction has subsided. This is kept up until 
at the end of 20 months 10 to 20 times the amount originally 
given is used. At the end of six months the horse is bled from 
the jugular vein, and from the serum of this blood the anti- 
toxin is obtained. 

The antitoxin is standardized by inoculating a guinea-pig 
weighing 250 grams with 100 or with 10 fatal doses of standard- 
ized toxin, with which has been incorporated an amount of anti- 
toxin believed to be sufficient to protect from the toxin. If the 
guinea-pig lives for four days, but dies soon after, the amount 
of antitoxin added to the toxin was just one unit. 

Pathology. A study of the exudate or pseudomembrane is 
the chief consideration in this section, though the pathological 
changes occurring as complications must be considered. 

The membrane may be situated on any mucous membrane of 
the body or upon the skin upon which there is an abrasion. In 

* Park: loc. cit. 



CONTAGIOUS DISEASES 405 

the order of frequency of involvement might be mentioned the 
tonsils, uvula, nasopharynx, nose^ conjunctiva, vagina, larynx 
and trachea. 

The exudate is grayish-white in color, and dips down into 
the mucous membrane beneath, being intimately attached, and 
leaves a bleeding surface when pulled off. It is composed 
mostly of fibrin, leucocytes and diphtheria bacilli in pure culture 
or mixed with the other organisms previously mentioned. 

The nerves are specially acted upon by the toxins, the periph- 
eral nerves being the ones chiefly affected. This degenera- 
tion may be parenchymatous, interstitial or fatty. The cord 
and brain may undergo degeneration also. The muscles may 
show" a degenerative change without nerve involvement. One 
of the principal muscles involved is that of the heart, fatty infil- 
tration and degeneration being the chief change. 

Bronchopneumonia is frequent, but chiefly due to the asso- 
ciated bacilli, streptococcus, staphylococcus and pneumococcus. 

The lymphatic glands, especially about the neck, are enlarged 
due to cell infiltration with occasional hemorrhages. 

The kidneys may show involvement also from the toxins, 
similar to the degeneration accompanying the other acute infec- 
tious diseases. The parenchyma and glomeruli are principally 
involved. 

Symptoms. The clinical classification, according to the loca- 
tion of the membrane, we consider the best. If a bacteriologic 
examination is made it may be further classified according to 
these findings, a pure culture of the diphtheria bacillus or a 
mixed infection, in which other bacteria are found in addition 
to the Klebs-Loefiler bacillus. These are chiefly the strepto- 
coccus, staphylococcus and pneumococcus. 

The onset is usually gradual; the child may complain of 
general malaise, beginning frequently with vomiting. The 
fever does not run a characteristic curve, its height and course 
depending upon the amount of toxemia, and amount of the indi- 
vidual resistance or immunity. In mixed infection it is apt 



406 



THE DISEASES OF CHILDREN 



to run much higher than in pure culture form. It is present 
to some extent in all cases averaging from 101° to 102° F. 

The pulse rate is always increased, depending upon the 
amount of toxemia, and not in proportion to the height of the 
temperature. A very rapid pulse is not a good sign. 

The child may or may not complain of its throat, may only 
have pain on swallowing, or severe dysphagia may be present. 



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FIG. 50. LARYNGEAL AND NASAL DIPHTHERIA; INTUBATION. 



The degrees of this symptom depends entirely upon the amount 
of infiltration in the tissues of the throat. 

The tonsils and uvula may be covered with a thick exudate 
and the child not complain of its throat, especially if it has 
been hurt previously in an examination of the throat, and if 
but a little sore, fears another examination. Hence, the impor- 
tance and the absolute necessity of examining the throat in 
every sick child as a matter of routine. 



CONTAGIOUS DISEASES 407 

The membrane described above is found on one or both tonsils 
or the uvula in addition. The glands are enlarged about the 
angle of the jaw and at the back of the neck. 

It refuses nourishment or takes very little at a time. The 
urine is high colored and much more scanty than normal. 
According to the amount of toxemia will albumin and casts be 
found. The urine should be regularly examined for albumin, 
and when present a microscopic examination made also, though 
a microscopic examination should be made as a routine measure. 

Generally a leucocytosis is present, its amount depending 
upon the membranous involvement. 

If there is nasal involvement there will be a discharge from 
the nostrils, which is apt to be blood tinged, and an excoriation 
of the skin of the upper lip occurs. There is an obstruction to 
the breathing through the nose and in the breast or bottle fed, 
nursing is interfered with. The nasal variety occurs infre- 
quently in the very yoimg, and it may be seen as a primary 
lesion, though it usually occurs as a complication of the faucial 
form. 

My experience has been that in primary nasal diphtheria the 
symptoms are as a rule more severe than in the uncomplicated 
faucial variety, though there are cases in which the diagnosis 
may not be made. "Where the diagnosis is not made, and the 
case looked upon as one of a severe ^^cold," it is a great menace 
as a distributor of the infecting organism. If both fauces and 
nares are covered with membrane the toxemia is apt to be very 
severe. 

If the membrane occurs in the larynx, as a primary condi- 
tion, there are apt to be three stages, the stage of invasion, in 
which the child is listless, has some fever, perhaps a slightly 
croupy cough, and lasts from a few hours to 24 ; the spasmodic 
stage, in which the membrane has formed. In this the croupy 
symptoms are exaggerated, the cough more spasmodic, there is 
very decided stridor, with recession of the suprasternal and 
supraclavicular spaces. As a late phenomenon, before the third 



408 THE DISEASES OF CHILDREN 

stage or stage of asphyxia occurs, the intercostal spaces and 
epigastric region recede with each inspiration. In the stage 
of asphyxia all of the extraordinary muscles of respiration are 
brought into play. 

From the beginning of the second stage, when obstruction 
has begun from the membrane forming, the child is restless, 
sleeps fitfully, and the depression is very profound. The pulse 
is accelerated out of ratio to the respiration. 

As obstruction advances there is cyanosis, blueness of the 
lips and about the nose, finger and toe nails, clammy skin, cold 
extremities, and imless relieved death quickly ensues. 

The enlargement of the lymph nodes of the neck, and at the 
angle of the jaw is quite marked in all of these forms. 

Complications and Sequelae. The Kidneys. Albuminuria oc- 
curs in about 60 per cent of cases, and in a smaller percentage 
there are evidences of a parenchymatous degeneration, hyaline 
and granular casts, with occasionally blood casts. 

Lungs. In the mixed-infection cases bronchopneumonia is 
a frequent complication. The consolidation is usually along 
the posterior borders of the lungs, patchy in its extent. This 
complication is less often seen in pure-culture forms of 
diphtheria. 

The first evidence of a complicating pneumonia is a sudden 
increase in the number of respirations with dilatation of the 
alse nasi and a rise in the temperature. 

Bronchitis is frequently seen evidenced by an increase in the 
cough, and respirations and slight rise in temperature. 

Nervous System. Perhaps the most important changes occur 
in the nervous system as a result of the toxemia. These compli- 
cations were more often encountered before the antitoxin was 
discovered. 

The changes are those of a fatty degeneration, usually, and 
it evidences itself by paralyses of various muscles. It most 
often begins during the stage of convalescence, perhaps several 



CONTAGIOUS DISEASES 409 

days after the case has been dismissed, though it may occur 
early. The group of muscles most frequently involved is of 
the throat, chiefly of the palate, and will not be noted until 
there is a regurgitation of liquids through the nose as the child 
swallows ; attempts at swallowing may be followed by spasmodic 
coughing from the liquid falling into the glottis. In this form 
of paralysis the muscles usually recover their tone in three or 
four weeks. 

Any part of the body may be involved, and the cases of sud- 
den death are most often due to a paralysis of the heart. 

Diagnosis. Considerable doubt may exist in one's mind as 
to the true condition existing in a case of membranous deposit 
on the mucous membrane of the throat or nose, which can only 
be decided by a bacteriologic examination. 

However in a case presenting a dirty-w^hite membrane in the 
throat or nose not easily removed, a slight rise of temperature, 
enlargement of the lymph nodes, with evident prostration, as 
the element of time plays so important a role in treatment, it is 
safe to administer the antitoxin at once and confirm the diag- 
nosis by bacteriologic examination later. 

Follicular tonsillitis is more often mistaken for diphtheria. 
In this the tonsils are enlarged, but the edema of surrounding 
tissue is not so great, and if seen early the follicles containing 
the whitish deposit are discrete. It is later, when these coalesce 
over the surface of the tonsil, that the diagnosis is doubtful, 
but there is no tendency for the membrane to spread. When 
coalesced it can be more easily mopped off. The constitutional 
symptoms are more severe and the onset more sudden. The 
temperature is higher also. General aching is present as a 
rule even in young children, and they complain when handled. 
However, even though the diag-nosis seems clear, especially when 
other children are in the house, a bacteriologic diagnosis should 
be made. 



410 THE DISEASES OF CHILDREN 

Quinsy, A peritonsillar abscess may be confounded with 
diphtheria. In a case under my observation recently the con- 
sultant laryngologist believed the condition a diphtheria, but at 
my request endeavored to find pus by an incision, without suc- 
cess. Twenty-four hours later spontaneous rupture of the 
abscess occurred below the incision, which confirmed my diag- 
nosis and cleared up all symptoms. There is very often an 
exudate over the affected tonsil and mucous membrane adjacent 
which can be removed without difficulty. 

If but one side is affected the swelling is chiefly of that 
side, and the edema of surrounding tissue quite severe. The 
patient talks as if the mouth was full of mush. 

Croup. This form of trouble may be either catarrhal or 
diphtheritic, and without visible membrane in the throat the 
diagnosis may be difficult. Direct inspection of the epiglottis 
is possible in the verj^ yonng, but not in the older children, and 
inspection by means of the laryngeal mirror is impossible in 
the child. 

In catarrhal croup the child is awakened by a harsh, brassy, 
spasmodic, croupy cough, having been put to bed usually with- 
out anything having been noticed unusual in its condition. It 
may have had a slight evidence of "cold" in the head for a day 
or so previously. There may be some stridor, with evidence 
of obstruction to inspiration, but without recession, and but a 
slight rise of temperature. By morning, as a rule, it is com- 
fortable, and but little cough is noticed, but when it does cough 
it is of the same brassy, harsh character. These symptoms have 
a tendency to recur for one or two nights subsequently. A few 
doses of ipecac, 20 or 30 drops of the syrup, or antimony and 
ipecac tablets (1/100 grain each), repeated at one- or two-hour 
intervals, a cold, wet compress to the throat and a steam-laden 
atmosphere for it to breathe, usually give relief in this form. 

Prognosis. This depends to a very great extent, in this day 
of antitoxin, to the promptness with which the diagnosis is 
made and the first injection of antitoxin given. 



CONTAGIOUS DISEASES 411 

It depends greatly also upon the age of the patient. The 
younger the child the graver the prognosis. The. site of the 
lesion also influences the prognosis. In purely tonsillar or 
pharyngeal cases the outlook is better, the nasal form less so, 
and the laryngeal cases very bad. The mortality in the laryngeal 
cases requiring intubation, even with the antitoxin, is very high. 

Treatment. In no disease has the mortality been so influenced 
as it has in diphtheria by the use of the diphtheria antitoxin. 
Statistics show the mortality has been reduced 50 per cent 
since the antitoxin era began. 

Prophylaxis. This is most important and is best accomplished 
by the medical inspection of schools; removal of diseased and 
enlarged tonsils and adenoids, strict quarantine of affected chil- 
dren ; careful disinfection of all bedding, clothes, feeding uten- 
sils and rooms vacated by those who have been affected ; bacterio- 
logical examination of the throat before the child is dismissed, 
with a general bath after leaving the room; extreme care on 
the part of physician and nurse when entering and leaving the 
sick room, and the immunization of the children in the family 
or ward exposed to it. 

Immunizing doses of antitoxin are usually advised as fol- 
lows: For infants 300 units, 500 units for children up to 15 
years, and 1000 units for adults. The immunizing properties 
of this dosage is usually about two weeks. This dosage should 
be repeated if it is desired to prolong the immunity. Since the 
introduction of the concentrated form of antitoxin the com- 
plications formerly seen are less frequent, viz., the rash and 
severe urticaria. 

After the child has recovered, the woodwork of the room 
should be first wiped down with a solution of 1/60 carbolic 
acid, and then disinfected with formaldehyd or formaldehyd 
and sulphur. 

Curative Treatment. As soon as the diagnosis has been posi- 
tively made, a curative dose of diphtheria antitoxin should be 
given. To a child of five years an initial dose of not less than 



412 THE DISEASES OF CHILDREN 

3000 units should be given. If the toxemia is severe, fever high, 
membranous exudate extensive, the dose should be 5000 units. 
Where no improvement follows within 8 to 12 hours a second 
injection should be made. In laryngeal cases the initial dose 
should not be less than 10,000 units. 

A large number of reliable antitoxins are upon the market 
now and one should be chosen which is furnished in a sterilized 
syringe with sterilized needle and attachments. 

The concentrated serums are preferable, as they less fre- 
quently cause the disagreeable rashes seen when larger volumes 
of blood serum were used. 

The effect of the serum is usually prompt and decided. The 
temperature falls 1° or 2° within two or three hours, the child 
soon becomes tranquil and falls asleep. The most typical effect 
is that upon the membrane, within 24 hours it begins to curl 
up at the edges, and gradually peels off and becomes detached 
either in its entirety or in pieces. The swelling and congestion 
of the mucous membrane become less marked. 

The serum is best injected in the tissue of the back between 
the shoulders or in the loin. The advantage of this is the child 
does not see the preparations for the operation and is easily 
held while it is being done. Careful preparation should be 
made of the skin by soap and water cleansing, followed by 
alcohol, the sterile covering of the needle not being removed 
until everything is ready. The point of injection is covered 
by an inch-square piece of zinc oxide adhesive plaster. 

Complications Following Antitoxin. More than 19 cases have 
been reported of sudden death following the use of diphtheria 
antitoxin. The cause of these fatalities has not been satisfac- 
torily proven, but it is supposedly in cases of so-called status 
lymphaticus, and death occurs within a few minutes after the 
injection. Some exhibit alarming symptoms, sudden dyspnea, 
fainting, cyanosis and feeble, rapid pulse with recovery. These 
are believed to be phenomena due to the horse serum and not to 



CONTAGIOUS DISEASES 4l3 

the antitoxin it contains, von Pirquet's theory being that they 
are due to the antibodies. 

Skin eruptions before the concentrated serum was used 
occurred quite frequently. These rashes were scarlatinaform 
or urticarial, when of the latter variety accompanied with great 
itching. Occasionally enlargement of the joints occurred. 
There is quite regularly a rise in temperature when these com- 
plications occur. 

General and Medicinal Treatment. Concentrated and nourish- 
ing food should be given, milk, in small quantities, and as often 
as every two hours ; animal broths and beef juice. Gavage and 
rectal nourishment should be used if necessary. Enemata for 
constipation; hydrotherapy for temperature over 102° F. ; 
sponge or tub baths. Stimulation is quite regularly indicated, 
and only a good bottled-in-bond whisky or brandy should be 
given. The quantity for 24 hours, half an ounce to an ounce, 
should be diluted with 2 or 3 parts of water, and this given at 
frequent intervals as indicated during the day and night. This 
can be supplemented by the hypodermic injection of strychnia 
or strophanthus by the mouth. 

Bromide and chloral, or Dover's powder, can be given in cases 
of extreme restlessness. Sedatives are usually indicated in the 
tube cases on account of the extreme restlessness from asphyxia 
and spasmodic coughing. Tonics following the attack are 
specially indicated. 

Local Treatment. Karely is it necessary to use any local 
treatment in these cases after the injection of the antitoxin. 
The exhaustion following the struggle always accompanying- 
swabbing of the throat is more harmful than if the throat is let 
alone. In the nasal form it may be necessary to irrigate the 
nose to open the nares. This is done by enveloping the child in 
a towel or sheet, holding it on its side on the nurse's lap, pro- 
tected by a rubber sheet, and with warm fountain syringe con- 
taining a boracic acid solution held 2 feet above its head, the 
upper nostril is irrigated, the solution returning through the 



414 



THE DISEASES OF CHILDREN 



lower one. Witli head slightly lower than the body there is no 
danger of the fluid being aspirated in the Inngs. 



INTUBATION. 



To the late Dr. Joseph O'Dwyer of 'New York is due the 
perfection of the intubation tube for the relief of stenosis of the 
larynx. In 1883, after many months of trial and experimenta- 
tion, Dr. O'Dwyer brought to the notice of the profession gen- 
erally the intubation tube which he had perfected. It is due to 
Dr. O'Dwyer' s memory to state that practically the only 
improvements that have ever been made in the tube were made 
by Dr. O'Dwyer himself before his death, the most perfect ones 




FIG. 51. o'dwyer intubation tubes. 

in use to-day being those made according to the O'Dwyer pat- 
tern. The tubes are made according to scale, usually in six 
sizes, corresponding to the age of the child. They are made 
of metal, gold plated, and have a central swell which holds them 
in position, and a head and narrow neck which fits in the chink 
of the glottis. 

In selecting the tube for the age of the child the scale is con- 
sulted, and the smallest tube which will remain in position is 
chosen. The tube reaches to within a short distance of the bifur- 
cation of the trachea. The rest of the set consists in a mouth 
gag, with which the child's mouth is held open; an introducer. 



CONTAGIOUS DISEASES 415 

upon the end of which is screwed the obturator, and an extractor 
or the extubator. In some of the late models of intubation sets 
each of the tubes contain an obturator permanently attached to 
the shank of the introducer, which is a safeguard against the 
obturator becoming unscrewed and remaining in the tube as 
the tube is pushed into place. Upon the side of the head of the 
tube there is a «mall opening into w^hich is inserted a piece of 
thread long enough to reach beyond the mouth of the child in 
order to make it easy to remove the tube in case the opening 
becomes blocked with dislodged membrane, or if it has been 
pushed into the esophagus instead of the larynx. 

Indications for Intubation. An intubation tube is never intro- 
duced unless positive indications for its use are present. If in 
spite of the use of the diphtheria antitoxin the child has increas- 
ing asphyxia, evidenced by cyanosis and marked retraction of 
the spaces above the sternum and the clavicles, of the intercostal 
spaces and the epigastric region, it is imperative, in order to 
save the child's life, that a tube be inserted. Under these condi- 
tions the patient is extremely restless, its respiration is very 
rapid and there is gradual deepening of the color to a deep 
cyanotic hue. 

Operation. O'Dwyer originally advocated the introduction of 
the tube with the child in an upright position, but it may be 
conveniently introduced with the child upon its back, with its 
chin slightly raised. The child should be wrapped carefully 
from shoulders beyond its feet in a sheet, thus confining its 
arms and legs. The child is held upon the right side of the 
lap of the nurse, its head resting against her chest, one of her 
arms encircling the lower part of the chest, the other steadying 
the head with hand upon the forehead. If enough assistance is 
at hand the nurse holding the child uses both arms to hold its 
body in position and the assistant steadies the head and holds 
the gag which has been introduced into the mouth. 

After selecting the proper tube the thread is placed in posi- 
tion through the hole in the head of the tube and the intubator 



416 THE DISEASES OF CHILDREN 

is examined to find if it can slip off the tube from the obturator 
easily. The thread is held firmly in the hand which is to be 
used to introduce the tube, the index finger of the unengaged 
hand is carried into the mouth and the epiglottis located, and 
the tube is then carried with the index finger as a guide directly 
into the larynx. With the attachment on the intubator the 
tube is slipped off its obturator and the obturator quickly with- 
drawn, the tube being pushed home by the finger still within 
the mouth. 

As soon as the tube has been pushed home there is an instant 
change in the character of the cough. It now becomes harsh 





FIG. 52. INTRODUCER. 

and brassy, and a good deal of spasmodic cough is caused. The 
child coughs more than it did before, and occasionally may 
cough up through the tube small pieces of membrane. After 
the first paroxysm of coughing the child usually falls off into a 
sound sleep, the cough gradually lessens and the whole picture 
is changed. 

Some advocate the leaving of the thread in the mouth, curling 
it up and placing it at the posterior margin of the tongue between 
the cheek and the gum, but this usually proves very unsatis- 
factory. As soon as it is certain that the tube will not be 
coughed up the finger is carried into the mouth after reintro- 
ducing the gag and with the finger on the tube the thread is cut 
and slowly withdrawn. 



CONTAGIOUS DISEASES 



417 



The length of time it will be necessary for the tube to be 
worn varies very greatly. Some cases have been reported that 
the tube could not be dispensed with before the end of three 
weeks. It is well, as a rule, to allow the tube to remain in 
position for not less than five days, and if at the end of this time 
the fever has subsided and the respirations are normal it may 
be safe to remove the tube, having everything at hand necessary 
for its reintroduction in case a spasmodic condition arises again, 
necessitating its reintroduction. 




FIG. 53. EXTRACTOR. 

During the wearing of the tube it is very necessary that the 
child be fed in the recumbent position, with its head Avell over 
the edge of the bed, or the nurse's lap, and below the level of 
its body. Usually the child is very easily fed in this position, 
and will either take its milk or food from a spoon or a bottle. 
This position was first suggested by Dr. Gassellberry of Chicago, 
and has been of very great service. Only liquids should be 
given until the tube is removed. 

This operatioii has practically entirely superseded the old 
operation of tracheotomy, which is the making of an opening 
in the trachea immediately below the cricoid cartilage. 



INCTTBATION AND QUARANTINE IN CONTAGIOUS DISEASES. 

The following is the report of the Committee on Quarantine 
of the Medical Society of the County of Dutchess (^ew York), 



418 THE DISEASES OF CHILDREN 

embracing suggestions regarding periods of incubation and 
quarantine in contagious diseases, and are reproduced because 
of their conciseness: 

SMALL-POX. 

Small-pox is considered the most infectious of all diseases. 
Period of incubation 1 to 10 days in the great majority of 
cases; shortest time S-J days, longest time 16 days. 

Prophylaxis. Vaccination, revaccination and isolation. Vac- 
cination may render one immune to the disease up to the fourth 
day after exposure. 

Quarantine should continue until all the affected epidermis 
is removed — the dried discs and scales contain infectious mate- 
rial. Each case is one unto itself, and no definite time other 
than stated can be given. 

DIPHTHERIA. 

Period of incubation 24 hours to 7 days. 

Prophylaxis. Isolation, disinfection, anti diphtheritic inocu- 
lation. Plenty of fresh air. 

Quarantine should continue until at least two cultures from 
the throat prove negative to the diphtheritic bacillus by bacterio- 
logical examination. 

MEASLES. 

The second most infectious disease with which we have to 
deal. Period of incubation, 9 to 11 days. 

Prophylaxis. Isolation during whole course of the disease. 

The disease may be transmitted from the first symptoms until 
after the desquamation, but as the eruption begins to fade the 
danger of transmission diminishes, and during the period of 
desquamation the probability of transmission is but slight. This 
point, however, is a mooted one. The rule is isolation until 
the skin is perfectly clear and normal, and there are no nasal 
or aural discharges. 



CONTAGIOUS DISEASES 419 

SCARLET FEVER. 

Scarlet fever is considered the third most infectious disease. 

Incubation. As short as 24 hours; as long as 21 days; aver- 
age, Y to 12 days. 

Prophylaxis. Isolation for a long time, at least until des- 
quamation has entirely disappeared and the skin is in its normal 
healthy state, and there are no nasal or aural discharges. Proper 
disinfection and hygienic conditions must exist during whole 
course of the disease. Desquamation in this disease is infectious 
as well as the discharges. Serum therapy has not been of any 
avail in this disease. 

GERMAN MEASLES. 

Period of incubation from one to four weeks, average time 
14 to 21 days. 

May be transmitted by contact and by fomites. Contagion 
seems to differ in different epidemics. The best authorities 
state that the contagiousness disappears with the eruption, 
therefore isolation should be enforced until the eruption has 
entirely disappeared. 

WHOOPING-COUGH. 

Transmitted by direct contact. 
Infection begins with the earliest symptoms. 
Period of incubation from one to two weeks. 
Prophylaxis. Isolation until at least the "whoop'' has dis- 
appeared. 

CEREBROSPINAL MENINGITIS. 

Transmitted or communicated through secretions of the 
mouth, nose and conjunctivae, but it has not been determined 
whether the disease is communicated to human beings by insects. 

Period of incubation from a few days to three weeks. 

Prophylaxis. Isolation, disinfection. Isolation should con- 
tinue until the mucous membranes are free from meningo- 



420 THE DISEASES OF CHILDREN 

COCCUS or the diplococcus (meningitiditis) intracellularis. 
Serum therapy has been used successfully in some cases. 

CHICKEN-POX. 

Period of incubation four days to a week. 

Prophylaxis. The person infected should be isolated during 
the entire eruption period and until the removal of the scabs. 

It must be considered as among the most contagious diseases, 
but the mode of infection is not given. 

MUMPS. 

Period of incubation 4 days to 24, average two weeks. 

Prophylaxis. The disease is transmitted even before the 
symptoms appear, and even as long as six weeks after the symp- 
toms have disappeared. 

In all cases of infectious or contagious diseases, all utensils, 
bedding, toweling and clothing of every kind should be thor- 
oughly disinfected and fumigated. Utensils, by the use of 
formalin, carbolic acid, creolin or bichloride solutions, care 
being taken that bichloride solutions do not come in contact 
with metal. All dejecta by the use of formalin, copperas or 
persulphate of iron solutions. Bichlorides are not recommended 
for use in dejecta as an albuminate is formed on the outside, 
and proper sterilization is therefore prevented. All bedding 
should be saturated in a formalin solution or one of bichloride 
solution before being sent to the laundry. Where there are 
proper facilities, all bedding, of whatever nature, should be 
thoroughly sterilized by superheated steam or by dry heat, espe- 
cially this should be done with all mattresses. In institutions 
where this cannot be done the mattresses and all bedding should 
be destroyed. The same should hold for private practice, but 
inasmuch as this procedure in private practice would work a 
hardship to a great many poor people the physician will be able, 
by thorough formalin disinfection and fumigation, to prevent 
the spread of the disease. The bedding, however, should be 



CONTAGIOUS DISEASES 421 

thoroughly saturated in a solution of formalin sufficiently strong 
to be effective. The wind will clear out the fumes. 

More care in the isolation and quarantine for measles, scarlet 
fever and whooping-cough should be exercised, because there is 
no known medical treatment to cut short the course of, or to 
render people immune to these diseases. With diphtheria and 
small-pox the old pest-house idea should be abolished, inasmuch 
as every one coming in contact with these two diseases may be 
rendered immune by the proper use of vaccine virus and serum 
therapy; the same is probably true of cerebrospinal meningitis. 



CHAPTEK XVII. 

Diseases of the Cikcueatoey System. 

the heart. 

Examination, Defects, Diseases. 

The heart is placed more horizontally in the chest of the 
child, and the apex beat is higher. During the first five or 
six years it is found in the fourth interspace, and slightly to the 
outer side of the mammillary line, and it gradually becomes 
lower as the heart enlarges, until it is found in the fifth inter- 
space. The outline can be made out by percussion with ease, 
because of the thinness of the chest wall, and for this reason 
light percussion is necessary. The relative dulness extends 
from the right border of the sternum to beyond the left mam- 
millary line. 

An examination of the heart should include careful inspec- 
tion, auscultation, palpation and percussion. From inspection 
we learn, in most cases, the location of the apex beat, the pres- 
ence or absence of dyspnea, and the character and frequence 
of the breathing; color of the skin and nails, position of the 
patient, shape of the finger tips ; the size of the liver and spleen, 
and the amount of gaseous distension of the abdomen. From 
auscultation, the character of the sounds of the heart, the pres- 
ence or absence of murmurs or a bruit or friction sounds ; char- 
acter of the breathing and of adventitious sounds, if heard. 
From percussion the relative area of dulness of the heart, size 
of liver, condition of the lungs, back and front. The finger is 
the best pleximeter and the hand and fingers the best percussion 
hammer. By palpation the apex beat can be located and its 
force determined, the character of the pulse determined. It 
can be learned. whether the pulse in the two wrists beats with 

422 



DISEASES OF THE CIRCULATORY SYSTEM 423 

the same volume, the frequency of the pulse and the character 
of the pulse wave. 

Etiology. Because of the peculiar susceptibility of the heart 
muscle and its lining membrane to bacterial invasion, and the 
influence of their toxins, the changes incident to these complica- 
tions in the infectious diseases as in typhoid fever, scarlet fever 
and diphtheria are greatly to be feared. 

Defects of the heart are frequently found at birth, the con- 
genital heart lesions^ which may either be the result of imperfect 
development or the persistence of fetal structures, as a patent 
foramen ovale, or a stenosis of the pulmonary or mitral orifices. 
Stenosis of the pulmonary orifice is usually due to fetal endo- 
carditis. 

The heart lesions, as the result of disease, are usually endo- 
cardial, and caused by the infectious diseases, with their organ- 
isms and toxins. 

The chief disease at fault is rheumatism, and, as mentioned 
in the section on that subject, a rheumatic heart may be present 
with but few or no joint lesions, the heart being practically the 
only manifestation of the disease. 

Scarlatina and diphtheriu cause serious heart lesions, mostly 
due to the effect of the complicating organism, the usual one 
being the streptococcus. Influenza as a cause of acquired heart 
disease is not generally believed, but I have seen it. Among the 
predisposing causes may be mentioned the seasons, violent 
physical exercise, anemia and chorea. 

CONGEI^ITAL HEART DISEASE. 

The most frequent form of congenital heart disease is the 
permanent patency of the foramen ovale. Congenital valvular 
lesions are also found, the chief being of the pulmonary orifices, 
as the right side of the fetal heart is more frequently involved 
than the left. The opening into the aorta is rarely affected, 
though it may be. 



424 THE DISEASES OF CHILDREN 

Symptoms. The chief symptoms of the congenital form of 
heart disease is the early cyanosis and the heart mnrmur. 

The cyanosis is quite marked, especially when the child cries, 
the skin and nails and mucous membranes are blue, and the 
name applied to these blue babies is morbus ceruleus. 

Bronchitis and hronchopneumonia are not at all infrequent 
in these cases from passive congestion, and principally involve 
the posterior border of the lungs. Clubbed fingers and toes are 
often seen. These children are backward mentally and 
physically. 

Dyspnea and orthopnea are frequent, and the pulse is much 
increased in frequency. With rupture of compensation edema 
of the low^er extremities takes place. 

Diagnosis. The diagnosis of pulmonary stenosis is made 
principally from the physical signs. The presence of a heart 
murmur and enlargement of the heart can be easily made. 

The murmur is systolic in character and as a rule harsh and 
loud, and heard distinctly over considerable area. The exception 
may be true, a soft-blowing murmur may be heard. It is heard 
usually best at the base and transmitted upward. 'No murmur 
may be heard. 

Auscultation may prove very unsatisfactory in regard to a 
correct diagnosis of the seat of the lesion. I recall one case in 
which a number of examinations were made by experienced 
diagnosticians, and numerous opinions given, and none were 
correct, as shown by the autopsy findings. 

A systolic murmur in the center of the precordial area not 
transmitted is suggestive of a patent foramen. 

Prognosis. This is always grave, since children with con- 
genital heart lesions, the blue babies, rarely survive the second 
year. If they do they do not reach puberty, as a rule. Stoelker 
gives 193 cases, 24 died in first six months; 42 before the end 
of the first year; 56 before the tenth year, and 71 before the 
twentieth year. 



DISEASES OF THE CIRCULATORY SYSTEM 425 

The degree of cyanosis and dyspnea influence the prognosis. 
If these children can be placed in proper surroundings in regard 
to home life, climate, etc., the prognosis is better. 

Treatment. The treatment is unsatisfactory as far as cure of 
the condition is concerned. It is largely symptomatic, with a 
general supervision over the diet, exercise, habits and clothing 
of the child. It should have tonics and nourishing food, which 
will not cause an attack of indigestion, and should be guarded 
against the contagion of the exanthemata and pulmonary dis- 
eases. Its clothing should be warm and changed according to 
the seasons, and in winter, if possible, it should be taken to a 
warmer, more equable climate, where an out-of-door life in 
the sun can be led. The exercise must never be violent, but 
under supervision. If digitalis is given as a heart tonic it should 
be in small doses, and increased in the presence of ruptured 
compensation. Strychnia or strophanthus are valuable adju- 
vants in an emergency. 

PERICARDITIS. 

Definition. This is an inflammation of the serous membrane 
enclosing the heart, the pericardial sac. 

Forms. It occurs as an acute condition, and two forms are 
recognized, the dry pericarditis and pericarditis with effusion. 

Etiology. Dry, Fibrinous, Plastic. It is most frequently a 
secondary condition to a general infectious disease. The bac- 
teria localized by Elexner are chiefly the micrococcus lance- 
olatus, streptococcus, staphylococcus aureus, bacillus pyocyaneus, 
influenza bacillus and the tubercle bacillus. Rheumatism has 
long been looked upon as a cause, and it may occur both during 
the attack and a number of days after the subsidence of the 
acute rheumatic symptoms. Eabcock mentions nephritis as a 
cause of pericarditis not often thought of. Trauma is also a 
cause. 

Pathology. The smooth serous membrane is injected, there 



426 THE DISEASES OP CHILDREN 

is an endothelial desquamation and the surface is roughened 
from a fibrinous exudate. Serofibrin or serum may be thrown 
off, enough to separate the two layers, but they may adhere and 
form fine fibrous bands or a more dense and firm set of adhesions. 

Symptoms. This condition may pass unrecognized unless an 
examination of the heart is made. Suspicion may be aroused 
by the rise of temperature, which follows beginning inflamma- 
tion of the pericardium. 

Pain is rather a constant and prominent symptom when the 
child is old enough to localize it. It may be referred to the 
precordial region, the epigastrium or even between the shoulders. 
As a rule it is not very sharp, but it may be very acute. 

The temperature is quite regularly elevated, to 102° F. or 
perhaps more. The presence of a rise in temperature, in any 
of the exanthemata or rheumatism, should cause the heart to be 
investigated. 

The pulse and respirations are both accelerated. There may 
be some cough, and loss of appetite is usual. 

Physical Sigfns. The prominent physical signs are those 
caused by the roughened pericardium, viz., friction fremitus 
and friction sounds. Deep pressure by the palpating fingers 
may decrease the fremitus felt on light palpation. The friction 
sound is usually best heard over the middle of the precordium, 
on both systole and diastole. The area of heart dulness is 
increased, quite decidedly so if there is any effusion. The heart 
sounds are apt to be somewhat muffled. 

Occnrrence. Poynton* gave some statistics of heart disease 
in children as follows: "Of 150 fatal cases of rheumatic heart 
disease, there was evidence of more or less acute plastic peri- 
carditis in all but nine. Tn 113 the pericardium was more or 
less adherent, while in 77 the adhesion was complete." 

Prognosis. This is always grave. Occurring as a complica- 
tion of rheumatism or of any of the exanthemata, it is espe- 
cially so. 

*Babcock — Diseases of the Heart. 



DISEASES OF THE CIRCULATORY SYSTEM 427 

Treatment. This is largely symptomatic, as there is no 
method of aborting the trouble. The heart condition is ben- 
efited by the use of remedies to combat the underlying disease, 
active antirheumatic remedies should be used freely when that 
disease is present. 

Application of an ice bag is of great assistance. A small 
and light one is used, and not filled to the top. A piece of flan- 
nel is placed next the skin and the ice bag on top allowed, grad- 
ually increasing the length of time until it is worn continuously. 
The opposite, hot applications, can be used but not with the 
same benefit. 

For the pain, discomfort, dyspnea and nervousness opium is 
of benefit. Heroin may be beneficially used. Hydrotherapy 
may be needed for the temperature, if it goes much above 102° 
F. The ice bag has a tendency to keep the fever down. 

Digitalis should not be given unless positively indicated, 
rather give strychnia as needed. 

PEBICABDITIS WITH EFFUSION". 

The exudate in this form may be serofibrinous, purulent or 
hemorrhagic. Its character cannot be determined unless an 
exploratory puncture is made and some aspirated. 

The pathology of these conditions is largely the same as the 
dry pleurisy, until the effusion takes place. 

Symptoms. The early symptoms before the effusion are those 
of the plastic or dry pleurisy, pain, slight cough, restlessness, 
rise of temperature and pulse, etc. As the effusion takes place 
the pain is relieved, and the symptoms then presenting are 
chiefly those of pressure. 

The sac is distended and the area of heart dulness is changed 
in shape, the rounded apex of the triangle being upward. The 
heart is displaced if the quantity of effusion is large, the apex 
beat being found to the outside of the left nipple, as a rule. 

The pulse is usually regular but compressible. It may be 
intermittent. 



428 THE DISEASES OF CHILDREN 

Rotch.* has suggested that a small triangular area of dulness 
is found at the lower right corner, which is easily made out. 

Prognosis. Depends upon the character of the fluid which 
is contained in the sac. The hemorrhagic form is usually quite 
rapidly fatal. Owing to the serious myocardial changes which 
may take place the prognosis in children is specially bad. 

Treatment. Practically nothing can be done to mitigate the 
condition other than has been recommended in the previous 
section. Rest, ice bag, blood letting, etc. The special indica- 
tions are absolute rest in bed, opium for pain and restlessness. 
Salines by the mouth occasionally and aspiration when it is 
indicated. 

Aspiration is done without much discomfort. The needle 
is introduced preferably in the fifth interspace, between the 
nipple line and the sternum border, and between the apex beat, 
if it can be located, and the lower border of the effusion, as 
shown by the flatness, all the fluid which can be removed being 
allowed to escape. If many pressure symptoms are present 
surgical interference is imperative promptly. 

Digitalis is used when indicated only. The fat-free tincture 
in 5 or 10 drop doses is the best preparation, and used for 
its effect. If diuresis is specially desired the infusion of digi- 
talis may be given with decided benefit, a teaspoonful to a 
dessertspoonful every three hours. 

Sleep may be insured by chloretone, in 2 or 4 grain doses. 
Codeine, gr. J to -J, especially indicated if there is any cough 
present; atropia if there is much dyspnea. 

CHRONIC PERICARDITIS. 

The process in this variety of pericarditis may be limited to 
the pericardium, or extend through to the tissues of the medias- 
tinum. In the latter form there are usually adhesions, more 
or less dense between the pericardium and the mediastinal. 

tissues. 

* Rotch: Pediatrics. 



DISEASES OF THE CIRCULATORY SYSTEM 429 

Pathology. As a result of the inflammatory process there is 
a new connective-tissue growth, principally, if intrapericardial, 
between the base of the heart and pericardium. Associated with 
the external pericarditis an inflammation of the adjacent pleura 
may take place, with adhesions between pericardium and pleura. 
Rarely an effusion may be present in this form. 

Etiology. Tuberculosis is usually the cause of the chronic 
form, and it may follow the recurrence of the acute form. It 
is not very common in children. 

Symptoms. There may be no special symptoms, save perhaps 
dyspnea on exertion, and Avhen secondary heart changes take 
place, edema, ascites, cough. Physical examination may not 
reveal any distinctive signs whatever in connection with the 
heart, but may reveal the presence of an hepatic engorgement. 
JSTo thing may be found during life whereby a positive diagnosis 
can be made, but at the postmortem the adhesions are found. 

Treatment. This is entirely symptomatic. The engorgement 
of the liver must be treated by appropriate remedies. 

PY^OPERICAEDIUM. 

This is a very rare and fatal condition. 

Etiology. It is oftenest due to a general pyemia, as may 
occur from otitis media, osteomyelitis, etc. In young children 
it may occur as a complication of pulmonary disease, notably 
empyema, and due directly to the pneumococcus. Sex plays 
no part in its causation. In 100 cases reported by Poynton^ 
83 per cent occurred before the fourth year, and two-thirds 
between the ages of one and three years. The exanthemata are 
predisposing causes. 

Pathology. The fluid found in the pericardium varies from 
fibrinopurulent fluid to a creamy pus. The pericardium is 
thickened and adhesions frequent. 

Symptoms. The beginning of the pericardial infection cannot 
be accurately told, as the friction sounds usually present in 

* British Medical Journal, August 15, 1908. 



430 THE DISEASES OF CHILDREN 

pericarditis are not nearly as often present as in the other vari- 
eties of pericarditis. 

This form may be acute, lasting several weeks, or chronic, 
running a much longer course. 

The child is ill from the beginning, dyspnea is prominent. 
The temperature is elevated and irregular, the pulse feeble and 
rapid. 

The usual signs are present if the effusion is large in amount. 
Muffling of the heart sounds; increased dulness over the pre- 
cordial region, especially upward toward the left clavicle. 

Prognosis. These cases are almost universally fatal, and 
many come to autopsy without the diagnosis having been made. 

Treatment. Supportive treatment and paracentesis of the 
pericardium offers the only hope of cure. The left lower margin 
of the cardiac dulness has been recommended as the point of 
selection. 

ENDO CARDITIS. 

Definition. An inflammation of the lining membrane of the 
heart, the endocardium, affecting chiefly that portion forming 
the valves. In fetal life it is the right side which is most 
affected. 

Etiology. The active cause of endocarditis is bacterial, and 
it occurs rarely as a primary affection, more often as a compli- 
cation, or as Babcock terms it, a manifestation of rheumatism, 
diphtheria and any of the acute exanthematous and infectious 
diseases. By far the most frequent causes are rheumatism and 
chorea. 

Pathology. The endocardium becomes cloudy, swollen and 
injected, with the chief pathologic process taking place in the 
valves, which are folds of endocardium. At the point of great- 
est strain there may be a break in the surface of the valve, and 
a deposit of fibrin at once takes place, becomes organized and 
forms what are called vegetations. These may be broken off, 
taken up by the circulation and form emboli. 



DISEASES OF THE CIRCULATORY SYSTEM 431 

Symptoms. Many cases of endocarditis present so few symp- 
toms that they go unrecognized, and the fact that the inflamma- 
tion has occurred is only determined by a chance physical exam- 
ination of the heart. Realizing the frequency of the occurrence 
of this manifestation, careful and regular and frequent exam- 
inations of the heart should be made. 

There may be a sharp rise in the temperature which has been 
on the decline, previously, perhaps, and with it pain in the 
region of the heart and dyspnea or air hunger.^ 

Physical Signs. The pulse shows a tumultous action, ill sus- 
tained and frequent, and a throbbing of the vessels of the neck. 
The heart sounds are roughened or muffled and there is prac- 
tically always a distinct blowing murmur heard over the pre- 
cordia with the point of intensity varying according to the valve 
involved. The murmur may entirely take the place of one of 
the sounds. 

Prognosis. The course of a simple or rheumatic endocarditis 
is toward recovery, but with the heart left in a crippled condi- 
tion, a leaky or an obstructing valve. Compensation may always 
exist, and the patient succumb to any other condition. Poynton 
points out the frequency of an inflammation of the heart muscle 
in fatal endocarditis. If a vegetation is washed ofl in the blood 
current and an embolus result, the prognosis is influenced 
according to the location of its lodgement. If in the brain, the 
outcome is serious, if not as to life, certainly as far as permanent 
recovery is concerned. 

Treatment. With the first evidence of chorea or rheumatism, 
the child must be put to bed at once and absolute rest in bed 
maintained throughout the attack. At. the first evidence of 
pain in the precordial region an ice bag should be applied, with 
a light piece of flannel between it and the skin. Heat in excep- 
tional cases may be more acceptable. 

The treatment is largely symptomatic, pain is controlled by 

* Babcock. 



432 THE DISEASES OF CHILDREN 

opium in some of its forms; bromides for the restlessness, and 
salines and calomel when indicated. 

The remedies which should be avoided are digitalis, aconite, 
veratrum viride and all of the coal-tar products. Digitalis 
increases systole and throws more strain on the valves ; veratrum 
and aconite depress the circulation too much, as do the coal- 
tar products. 

Strychnia is a valuable agent later, after the acute symptoms 
have subsided. 

The diet should be the most easily digested, those foods which 
have a tendency to form gas which would cause pressure symp- 
toms should not be given at all. 

MALIGNANT ENDOCARDITIS. 

Synonym. Acute ulcerative endocarditis. 

Definition. This condition is an inflammation of the endo- 
cardium and occurs as a manifestation or complication of gen- 
eral septic troubles, and is rather infrequent in children. 

Etiology. This is essentially a septic condition due to the 
action of the pus-producing organisms in the endocardium, of 
which the most commonly found are streptococci, staphylococci, 
pneumococci and diphtheria bacillus. The process is more apt 
to be engrafted upon an endocardium previously inflamed. 

Pathology. In children, in whom ulcerative endocarditis is 
comparatively rare, the process is the same as in adults. There 
is an exaggeration of the condition found in simple endocarditis. 
As its name implies, there may be an ulcerative condition affect- 
ing chiefly the valves, and emboli are more apt to occur. These 
emboli are vegetations full of the infecting organisms, and a 
similar process begins wherever they lodge. 

Symptoms. The symptoms are those of a general septic con- 
dition, and unless a special examination is made of the heart, 
attention at first is not called to this part at all. The patient 
is in a typhoid state. The fever is usually decidedly intermit- 
tent in character and inclined to be irregular, perhaps preceded 



DISEASES OF THE CIRCULATORY SYSTEM 433 

by a chill, frequently reaching high, 105° F., or over. The skin 
is hot and dry, except during the free sweats, which are apt 
to be a feature; the tongue dry, the bowels loose, loss of appe- 
tite, the pulse weak and often much accelerated. The patient 
looks profoundly impressed by something and the anemia is 
progressive. 

The physical signs may be very indefinite, perhaps a blowing 
murmur, perhaps none. If the patient develops symptoms of 
a septic nature, following on a simple endocarditis, the diag- 
nosis is usually plain. 

Prognosis. The prognosis is grave, nearly all cases dying 
promptly. 

Treatment. Beyond removing the cause of the general septic 
condition, if possible, a nutritious diet, judicious stimulation 
and rest, there is little that can be done. The antistreptococcic 
serum might hold out some hope of relief. 

CHRONIC ENDOCARDITIS. 

The form of endocarditis usually referred in children to 
which the term chronic is applied, is that which follows the 
acute endocarditis. 

Pathology. The process following an acute endocarditis is 
that of repair, an absorption of the vegetations on the valves 
and the formation of connective tissue. This may result in a 
deformity of the valves preventing their perfect closure, allow- 
ing a backward flow of the blood, a regurgitation or insufficiency, 
or an interference to the free flow of the blood through the 
valve, a stenosis or an obstruction. 

If the heart muscle develops in proportion to the dilatation 
of the heart cavities, resulting from the overwork because of 
the obstruction at the valvular orifice or a damming back of 
the current, there is said to exist a compensation. As long as 
compensatory hypertrophy exists practically no symptoms are 
present, and unless the chest is examined it may go unrec- 
ognized. 



434 TtlE DISEASiJS OF CHILDREN 

The symptoms of ruptured compensation are practically the 
same in all the valvular lesions. i 

MITKAL KEGURGITATION. 

In this condition the mitral valves are incompetent to hold 
the blood of the left ventricle from regurgitation into the 
auricle during ventricular systole. 

Pathology. The cusps may be so stretched as to overlap and 
allow leakage ; one valve may be contracted following the deposit 
of fibrous tissue. The left auricle receives blood from the lungs 
and from the ventricle at systole, consequently it quickly becomes 
dilated, and because of this crowding it is hypertrophied in its 
attempts to empty itself. When this compensation exists no 
trouble results, but when the auricle is overpowered the blood 
dams back upon the lungs and serious symptoms supervene, 
passive congestion in many important organs resulting. This 
condition is a very common one among children. 

Symptoms. Practically no symptoms exist during the main- 
tenance of compensation. There may be a visible difficulty in 
breathing on violent exertion, such as running or rushing up 
steps, with a coincident increase in the pulse rate. Children, 
however, rarely complain of this, and unless they evidence some 
pallor after taking this undue exercise, it may not be recognized. 
These children may develop colds more readily, and owing to 
the strain upon the right side of the heart on coughing this 
symptom should be closely watched. 

With rupture of compensation and the general passive con- 
gestion there is bronchitis; catarrhal gastritis; enlargement of 
the liver; engorgement of the hemorrhoidal vessels; nephritis; 
cyanosis and dyspnea. Dropsy is one of the last symptoms to 
develop. 

Physical Signs. Inspection. With the chest bared the apex 
beat is found displaced downward and to the left, owing to the 
left ventricular hypertrophy. If the right ventricle is enlarged, 
epigastric pulsation may be noted. 



DISEASES OF THE CIRCULATORY SYSTEM 435 

Palpation. I^othing of special diagnostic importance is found 
by palpation, except to confirm the location of the apex beat. 
The pulse is faster and not well sustained in volume. 

Auscultation. There is a systolic murmur, or bruit, loud and 
blowing, and heard most distinctly over the apex beat. It is 
transmitted under the arm and posteriorly. It is synchronous 
with the first sound of the heart, and it may take the place of the 
first sound entirely. The second sound is accentuated. 

Prognosis. This depends entirely upon the existence of com- 
pensation. It is always grave when compensation ruptures. 

MITRAI. STENOSIS. 

This is an interference to the flow of blood from the auricle 
into the ventricle, and is usually due to an endocarditis. 

Pathology. The obstruction may be caused by a deposit on 
the valve or at the valvular orifice, narrowing the orifice in 
either event. In consequence the auricle is dilated and hyper- 
trophied, and the left ventricle is relatively smaller in size. A 
right ventricular hypertrophy takes place from increased work 
thrown upon it by passive congestion of the lung. This lesion 
is less frequent in children than in adults. 

Symptoms. There are very few symptoms in the absence of 
ruptured compensation. Dyspnea is present on the slightest 
exertion, digestive disturbances are common, and these children 
are below par physically. Cough may be present, edema devel- 
ops early, congestion of the kidneys follows, and then ascites. 
Cyanosis of the skin and nails develops also. 

Physical Signs. Inspection. A distinct impulse may be seen 
at the base, with feeble apex beat, which is displaced outward, 
somewhat. Clubbing of the fingers is quite noticeable. 

Palpation. An important sigji is thus elicited, the presystolic 
thrill being felt. This is a distinct thrill, felt just before the 
ventricles contract in the fourth and fifth interspaces, inside 
the mammary line; a pulsation can also be felt in the epigas- 
trium. The pulse is of less volume than normal and slowed, 



436 THE DISEASES OF CHILDREN 

and the left radial may be found the weaker. Percussion shows 
an increased area of dulness downward and to the right. 

Auscultation. There is a presystolic brnit, heard with great- 
est intensity above and to the right of the apex beat, and not 
transmitted. The murmur is much rougher and harsher than 
the regurgitant murmur. The sounds of the heart are normal, 
except perhaps an accentuation or the reverse of an indistinct- 
ness of the pulmonary second sound. Babcock describes a 
' 'doubling of the second sound, limited to the mitral area, or the 
apex." 

Prognosis. This is one of the graver of the valvular lesions. 
The child is stunted in its growth, and from five to ten years 
may be the limit of its existence. Pulmonary complications are 
usually the cause of death. 

AORTIC REGURGITATION. 

Synonyms. Aortic insufficiency, hicompetency. 

In this condition the left ventricle can never completely 
empty itself as the aortic valves are incompetent to prevent the 
blood flowing back immediately into the ventricle during 
diastole. 

Pathology. In children the condition is due to an endo- 
carditis, is inflammatory, and as a result the cusps are con- 
tracted or held down by bands, making perfect closure impos- 
sible. Vegetations may be so placed on the edge of the valves 
as to prevent closure. 

In this condition an enlarged left ventricle is the first change 
noted, and as it enlarges it may cause an incompetency to develop 
in the mitral orifice. Compensatory hypertrophy occurs early, 
and the wall of the ventricle may be very thick, 1 or 1^ inches 
thick. This heart is called the beef heart or cor hovinum. 

Symptoms, As in the other conditions, as long as compensa- 
tion exists, there may be no special symptoms. Palpitation is 
not infrequent and may be the only symptom. It is to the pulse 
one must look for rupture of compensation, It becomes weaker, 



DISEASES OF THE CIRCULATORY SYSTEM 437 

and the typical Corrigan pulse is felt if the child's hand is 
elevated above its head. The pulsations are not even or regular. 

Physical Signs. Inspection. Visible pulsation may be noted 
in the larger arteries of the body, notably the carotids, but this 
is not as frequently seen in children as in adults. The apex beat 
is displaced downward perhaps as much as two spaces, and 
outward. 

Palpation. The cardiac impulse is quite strong, the heart's 
action being tumultuous. The charcteristic Corrigan or water 
hammer pulse is present. In this phenomenon the child's hand 
being held higher than its head, the finger on the radial artery 
feels the strong pulsation, and the artery immediately collapses. 

Percussion. This shows the extent of the enlargement of the 
heart, the area of dulness extending farther downward and to 
the left than normal. 

AORTIC STENOSIS. 

This lesion is more rare in children than in adults, being 
quite infrequent in adults. 

There is a narrowing or obstruction of the orifice of the aortic 
valve. 

Pathology. As in the mitral stenosis there may be adhesions 
holding the valves to prevent their closure, and at the same time 
obstructing the floAv, and vegetations may narrow the opening. 
Congenital narrowing of the orifice and aorta itself may rarely 
be present. From overwork in forcing blood through a con- 
stricted opening, the left ventricle is enlarged, hypertrophied. 
As a result of beginning rupture of compensation the left auricle 
becomes enlarged from forcing blood into a partly emptied 
ventricle. 

Symptoms. As a rule more serious symptoms are present in 
this form of valvular lesion than any other, though, as in the 
others, no symptoms may be present. With beginning rupture 
of compensation the child is anemic, incapable of the least exer- 
tion, either mental or physical, and is dyspneic. 



438 THE DISEASES OF CHILDREN 

Mitral regurgitation frequently occurs as a complication of 
aortic stenosis. 

Physical Signs. Inspection. Displacement of the apex beat 
downward and outward owing to the enlargement of the left 
ventricle. j, 

Palpation. A systolic thrill may be felt at the base, along 
the course of the aorta especially. The pulse is weak because 
of the lessened volume of blood filling the artery. The artery 
does not fill with each pulsation. 

Percussion. This only confirms the enlargement of the left 
ventricle by the area of dulness being displaced downward and 
to the left. 

Auscultation. Over the aortic, or second right interspace, 
there is a systolic murmur heard with the first sound, and trans- 
mitted upward in the great vessels of the neck. It may follow 
the blood stream down the aorta and be heard between the 
scapulae. 

Prognosis. Depends on the amount of compensation on rup- 
ture of compensation, the prognosis is very grave. Death does 
not occur suddenly in this form. 

TRICUSPID REGURGITATION. 

This is the principal right side heart lesion, and is chiefly 
the result of fetal endocarditis. 

Pathology. The right ventricle and auricle are enlarged and 
the walls of both are thinned. There are usually other valvular 
lesions associated with this form. 

Symptoms. Cyanosis and swelling of the veins of the face 
and extremities is an early manifestation of this damming back 
of the venous blood current. The congestion extends to the 
abdominal viscera, the liver and the hemorrhoidal plexus of 
veins are enlarged. The child is incapable of exertion, and when 
it cries there is an evident cyanosis. Dropsy of the extremities 
may develop. Hydrothorax may occur,* 

♦Gibson. 



DISEASES OF THE CIRCULATORY SYSTEM 439 

Physical Signs. Inspection. Enlargement of the veins of the 
neck are quite prominent, and in the event of ruptured compen- 
sation venous pulsation is seen. 

Palpation. The venous pulse can be felt ; also one in the liver 
if this organ is palpated. 

Percussion. Increase in area of cardiac dulness to the right 
and even below the ensiform cartilage. 

Auscultation. A blowing, systolic murmur is heard best over 
the tricuspid interspace, second, left. It may also be heard 
loudly at the ensiform cartilage. 

Prognosis. This is relatively grave, more so if associated with 
lesions at other orifices. 

TRICUSPID STENOSIS. 

This is a very rare and practically unknown condition in 
children. Babcock^ refers to only 1154 cases which had been 
recorded in medical literature. 

Pathology. The same morbid anatomy exists as in mitral 
stenosis. 

Etiology. A fetal endocarditis in congenital cases and rheu- 
matism in those developing after birth. The most recorded 
cases occur between 20 and 30 years, and more females affected 
than males. 

Symptoms. The majority of cases evidently go unrecognized. 
Visceral engorgement is the principal manifestation. 

Physical Signs. Palpation shows the pulse weak and variable. 

Auscultation. Like the other physical signs the sounds are 
indefinite. A presystolic murmur may be heard in the tricuspid 
area. 

Combined Valvular Lesions. Any two or several of the val- 
vular lesions described may be associated in the same individual, 
as mitral stenosis and aortic regurgitation; a double mitral 
lesion ; mitral and aortic stenosis, etc. 

* Babcock: Diseases of the Heart and Arterial System, 



440 THE DISEASES OF CHILDREN 

The Treatment of Valvular Lesions. The physician should 
have control of the child's habits of life, its diet, exercise, cloth- 
ing and sleep. The amount allowed of each depends largely 
on the presence or absence of compensation. If compensation 
exists the whole effort of treatment is to maintain it. The exer- 
cise must be under supervision. The nurse or companion should 
notice carefully for over-fatigue, symptoms of dyspnea or pallor, 
and stop violent play at once. Mitral stenosis demands more 
care than any of the rest. Young boys should be warned and, 
if possible, prevented from using tobacco. The clothes should 
be prescribed, not too light, but warm and protective. Bathing 
to obtain an active skin is most important. The diet should be 
so regulated that no residue for fermentation is left in the bowel 
and stomach. Any intercurrent disease must receive careful 
attention, especially epidemic influenza and tonsillitis. 

Too much emphasis cannot be placed upon the importance of 
digitalis, both as a poison and a drug of value. Too many 
physicians use this drug as a regular and routine remedy, no 
matter whether the indication is present or not. It is capable 
of doing great injury, and should be used only when a positive 
indication presents. With compensation present, digitalis is 
not indicated. 

Laxatives should be used when indicated and the formation 
of toxines and intestinal gases prevented if possible. 

When rupture of compensation exists, active and judicious 
treatment is indicated. Every condition which interferes with 
proper aeration and nutrition should be removed. If adenoids 
are present they should be removed, if a gastric catarrh is pres- 
ent it should receive attention, diet should be so regulated that 
no fermentation takes place. 

Digitalis, in the presence of ruptured compensation, is of 
great value, the fat-free preparation being employed. Strophan- 
thus may be used instead. Strychnia is of value as a remedy 
and its effect noted carefully. Its cumulative effect has been 
observed with muscular twitchings prominent. 



DISEASES OF THE CIKCULATORY SYSTEM * 441 

Rest is an important aid in the treatment, special symptoms 
are treated as they arise. 

FUNCTIONAE DISORDEES OF THE HEART. 

ISTeuroses of the heart in an otherwise normal heart are not 
common in young children. The two conditions most often met 
are bradycardia and tachycardia. 

BRADYCARDIA. 

This is an abnormally slow pulse rate, below 60 pulsations 
per minute. Very rarely the pulse may be found normally much 
slower than 60. Several in the family may have a slow pulse. 

Etiology. Heredity may be a factor in its causation. It 
has been noticed ix) occur in masturbation in a child. It may 
occur during the course of or convalescence from the acute infec- 
tious diseases; diseases of the gastroenteric tract; in degen- 
erative or inflammatory conditions of the heart muscle; in 
uremia ; and in diseases of the central nervous system. 

Symptoms. ITo special symptoms- are present except a very 
slow pulse. There may be a disinclination to and perhaps an 
inability for violent play or exercise. 

TACHYCARDIA. 

This is an opposite condition from bradycardia, the heart's 
action being very rapid. 

Symptoms. Apparently without cause and without warning 
the heart begins to beat very rapidly, tumultuously and irreg- 
ularly. The pulse is accelerated to 110, or not quit€ so high, 
and may reach 140 or 150. Palpitation may be a feature of 
the case, and oppression of breathing. A diagnosis from Grave's 
disease must be made in all cases. 

Treatment. Eemoval of the cause, if possible ; control of the 
diet and limitation foods which ferment; carefully regulated 
exercise and regular bathing. 

If palpitation is a feature, morphine will be of most benefit ; 



442 THE DISEASES OF CHILDREN 

the bromides may control the attack; nitroglycerine is given in 
certain cases; aromatic spirits of ammonia. If there is pain, 
an ice bag can be applied to the precordial region. 

ACUTE MYOCARDITIS. 

Definition. This is an inflammation of the heart muscle. 

Etiology. It may occur independently of endocarditis or 
pericarditis, but secondary to infectious or septic diseases, 
notably diphtheria. 

Pathology. The muscle of the thicker ventricular walls is 
chiefly involved, and the process has been described as paren- 
chymatous and interstitial. There is a granular degeneration, 
the muscle fibers are soft and the muscle itself flabby. Pus 
may be found in the muscle wall in the interstitial form, this 
form occurring as a sequel to pyemic conditions. 

Symptoms. Occurring as myocarditis does, as a sequel to 
infectious diseases, diphtheria especially, the symptoms appear 
as convalescence seems established. The most noticeable con- 
dition is a weakening of the heart's action, which may be evi- 
denced by the character of the pulse, pallor, apparent shock 
and inability to exercise in the least. The pulse is accelerated, 
regular as to time, but irregular as to force and volume. Because 
of the feebleness of the heart's action, there is no apparent apex 
beat, and the sounds are indistinct and muffled. Vomiting may 
be present without apparent cause. Pain in the precordial 
regioijL may be present. 

Prognosis. Sudden death is not uncommon in these cases. 
The child may be playing about, apparently normal, fall and 
expire in a remarkably short time. The pulse returning to 
normal is the best sign of improvement. 

Treatment. Prevention, if possible. The earlier diphtheria 
antitoxin is used the less chance there is for a myocarditis devel- 
oping. Absolute rest in bed, with easily digested food. Pain 
is relieved by codeine or morphine, strychnia is a very important 
adjuvant, and tonics during convalescence, cod liver oil and 
iron especially. 



CHAPTER XVIII. 

Diseases of the Blood. 

the blood of infancy and childhood. 

A study of the blood is a most important diagnostic aid in 
many febrile and other conditions in infancy and childhood. 
An examination of the blood is proceeded with as follows : The 
lobe of the ear should be selected for the puncture. It is 
cleansed with a damp sterile or clean cloth and dried. With a 
triangular-pointed needle, lancet, or large sewing needle, the 
skin at the lower edge of the lobe is quickly punctured. The 
first few drops of blood are wiped off, and the next can be used 
for diagnostic purposes. If to be examined at once, with a 
cover-slip touch the center to the drop of blood without touching 
the skin and drop the cover-face down on a clean glass slide. 
From the examination of this slip can be learned whether there 
are any plasmodium malarial or the blood parasites; relative 
number of white cells, number and character of the red blood 
cells, and whether there is an increase in the ^'blood plates." 

Counting the blood corpuscles is done best by a Thoma Zeiss 
counter. To do this, the blood is drawn in a special pipette, 
diluted and mixed, placed in the chamber of the counting slide 
and the corpuscles counted. If the distribution of the cells seems 
uniform over the ruled disc, the counting is begun. An objec- 
tive Leitz 5 or Zeiss D and a ^o. 1 or 2 eyepiece are )>est u^':d. 
When the number of corpuscles in 360 squares has been couniod 
the number must be divided by 360, and multiplied by 800,000, 
which gives the number of corpuscles in 1 cubic millimeter. 
These figures and the amount of dilution are marked on llie 
pipette. 

The pipette should be cleaned and dried as soon as the count- 
ing has been completed. 

443 



444 THE DISEASES OF CHILDREN 

In counting the white cells the 'Svhite counter" is used, and 
a diluting solution which renders the red cells invisible. 

Hemoglobin may be estimated by means of Tallquist's, Oli- 
ver's or Von rieischl's hemoglobinometer. The Tallquist scale 
is used by soaking into standard filter paper a drop of blood 
and comparing it with a water-color scale of 10 tints, and is 
accurate enough for bedside test, an error of not more than 
10 per cent being made. 




FIG. 54. TALLQUIST HEMOGLOBIN SCALE. 

Oliver's instrument consists of a series of 12 tinted-glass 
discs arranged in two rows, the color scheme corresponding to 
hemoglobin percentages of from 10 to 120. 

Y. Fleischl's instrument, the cell holding the diluted blood, 
has a moving color scale underneath, with reflected light shining 
through it. The scale is moved back and forth until the color 
of the glass is the same as the blood. The percentage of hem- 
oglobin is given on the scale. At birth the hemoglobin percent- 
age is high, usually 100, but after a month or so decreases to 
60 or 80. 

Red Blood Corpuscles. The blood being spread thickly shows 
the red cells in rouleaux, hence thin spreads must be made if 
the cells are to be examined. They are round, biconcave, vary- 
ing little in size in health, averaging about 7.5 ^. 

In disease the red cells may be very small, 2 )tt to 4 jtt micro- 



DISEASES OF THE BLOOD 445 

cytes, or they may be very large, 10 /* or even 20 /a, megalocytes, 
when misshapen they are called poikilocytes. 

During fetal life nucleated red cells are found, but they dis- 
appear as the number of red cells decrease and only recur as 
a result of disease. The nucleated red cells are divided into 
the normoblasts, megalohlasts, microhlasts. The first is an 
immature red cell, the nucleus staining very dark. It is found 
in severe anemias, chlorosis, etc. 

The megalohlast is a very large cell (11 to 20 /i) with large 
nucleus, and occurs in certain grave forms of anemia, its 
protoplasm stains irregularly. The microhlasts are much 
rarer than either of the other. 

White Blood Corpuscles. The following varieties of white 
corpuscles are recognized: 

1. Polymorphonuclear neutrophilic leucocytes or the poly- 
nuclear leucocytes. Thesd cells comprise most of the white 
blood corpuscles, and are those found in pus. They are irreg- 
ular in shape and none are exactly alike, and stain deeply with 
basic dyes. 

2. Lymphocytes. These are referred to as lymphocytes and 
large mononuclear cells. The lymphocyte varies in size from 
size of red cell to larger, and has a large nucleus which stains 
easily. The large cells are much larger than the lymphocytes 
and have an oval nucleus. 

3. Eosinophiles. These cells are polymorphous. The gran- 
ules are 1 ju. in diameter. They take the Wright stain and show 
a brilliant eosin tint. 

4. Mast Cells. These stain with Wright's stain. They are 
twice the diameter of the red cell. 

The frequency of the various white cells is given as follows : 

Adults^ 
. Infancy* Per cent. 

Lymphocytes 40 to 60 20 to 30 

Large mononuclears 4 to 5 

Polynuclears 18 to 40 62 to 70 

Eosinophiles 2 to 4 ^ to 4 

Mast cells iV to ^ 

* Carr: Practice of Pediatrics. f Cabot. 



446 THE DISEASES OF CHILDKEN 

Myelocyte. This cell is found normally in the bone marrow, 
and is found in the blood stream only under abnormal condi- 
tions, as in diphtheria. It stains best with Ehrlich's stain. It 
has a large number of granules, and they take the acid dyes. 

Degenerated Leucocytes, which are chiefly degenerated lymph- 
ocytes and large mononuclear lymphocytes. 

Number of Leucocytes. In the blood in infancy the number 
of leucocytes is greater than in adults. At birth they may 
reach 20,000 to 25,000. In a w^eek or so the number falls to 
9,000 to 15,000, and later in childhood they are still fewer in 
number, 7,000 to 10,000. After the third year they will average 
8,000. 

General Consideration of Blood Changes. The examination of 
the blood should be considered in the light of a clinical phe- 
nomenon. Stained smears show the relative number of white 
and red corpuscles, and to the trained eye this is often equiv- 
alent to a differential count. The stain also shows the Plas- 
modia malaria, filaria and other blood parasites, as well as 
the character of the red cells. 

There may be a decrease in the number of red blood cells, 
as in the anemias. There is a temporary increase in their num- 
ber in cyanosis. 

Physiologically there may be an increase in the number of 
the white blood cells. This occurs normally after digestion, 
exercise and cold baths. A transitory increase is termed leu- 
cocytosis. The term relative leucocytosis is used when there 
is an increase in any type of leucocyte, as lymphocytosis^ eosino- 
philiaj neutrophilic leucoytosis. 

Leucocytosis, as stated, is the rule in the blood of infants and 
occurs as a result of intestinal disorders, congenital heart dis- 
ease, rachitis, chronic tuberculosis, toxemias, diphtheria, syph- 
ilis, pertussis, pus conditions, etc. 

Leucopenia is used to describe a decrease in the total number 
of leucocytes. 



DISEASES OF THE BLOOD 447 



AKEMIA. 



It must be borne in mind in the examination of the blood of 
infants, the normal tendency to a lymphocytosis and the lower 
hemoglobin percentage, when compared with adults. 

In anemia there is a deficiency in the red blood corpuscles 
and in the hemoglobin percentage. With these changes there 
may be a decrease in the total volume of blood. The anemias 
are classified as primary and secondary. 

Primary Anemia. Definition. By this form is generally 
understood the anemias, the cause of which is unknown, as per- 
nicious anemia, there being a grave blood condition, enough to 
cause death, yet the underlying cause not known, and chlorosis. 

Secondary Anemia. Definition. This can be described as a 
symptomatic (Cabot) anemia, the blood changes being due to 
certain conditions which are more or less well known, as hemor- 
rhage, tnalaria, syphilis, tuberculosis, gastrointestinal disease, 
scorbutus, rachitis, etc. 

In the secondary form of anemia there is a diminution in the 
coloring matter, the number of cells remaining near normal. 
It presents in the form in which the red cell is deformed, poi- 
hilocytosis ; they may change as regards their staining qualities ; 
the formation of nucleated red cell, the normoblasts, megalo- 
blasts and microblasts. 

PERN-ICIOUS AI^EMIA. 

Synonyms. Progressive pernicious anemia; anemia infantum. 

Definition. This is the form of anemia which is generally 
fatal, and presents a definite blood picture without apparent 
cause. 

Etiology. This is not known, save that the so-called simple 
secondary anemias have been known to develop into the perni- 
cious form. The anhylostoma duodenale has been given as a 
cause in the South. It has been estimated* as occurring in 

* Lazarus; Nothnagle: Diseases of Blood. 



448 THE DISEASES OF CHILDKEN 

about 2 per cent of all internal diseases. It occurs slightly 
more often in males and with great rarity under ^ve years of 
age. Rotch did not find a single case in 2000 cases of children's 
diseases in the Children's Hospital of Boston. Stengel believes 
the bothriocephalus may produce this form. 

Pathology. The anemia, pallor and the extravasations of 
blood into and the fatty degeneration of the internal organs is 
noticeable at once. Free iron is found in the internal organs, 
especially the liver. The chief pathologic changes are in the 
heart. The central nervous system and cord show the same 
hemorrhagic condition as the other organs in addition to anemia. 

The bone marrow in this disease differs from the normal in 
that there is a large increase in the megaloblasts. 

The red cells are markedly decreased, averaging from 1,500,- 
000 to 1,000,000. The hemoglobin is usually decreased, but 
not in proportion to the reduction in red cells, but the opposite 
may as frequently be seen, viz., a relatively high hemoglobin, 
considering the diminution in red cells. The amount of blood 
is usually reduced and coagulation in fresh blood is much 
slower. The fresh blood looks pale in color. The number of 
leucocytes is also reduced. The blood does not show the usual 
rouleaux formation. The oval-shaped red cells may predominate. 

Symptoms. The onset of pernicious anemia is insidious. It 
may at first be diagnosed as a simple anemia with gradually 
increasing debility and lack of energy, with decreased endur- 
ance. Pallor of the skin followed by a distinct lemon-yellow 
color, develops very soon. Anemia of the mucous membrane 
follows; there is dyspnea, anorexia, perhaps nausea and vom^it- 
ing, loss of flesh and edema. Palpitation is frequent on the least 
exertion or excitement. Small hemorrhages may occur in the 
conjunctiva and the skin. Hemic murmurs are frequent. Fre- 
quently distinct remissions occur, when there is an apparent 
improvement in all the symptoms. 

There is an increase in the number of the red cells, approach- 
ing normal, a decrease in the megaloblasts and increase in the 



DISEASES OF THE BLOOD 449 

normoblasts. There is an increase in the leucocytes, mostly the 
polymorphoniiclear neutrophiles. 

The digestive symptoms are improved and the palpitation 
lessened or absent entirely. 

These remissions may be permanent, the case progressing 
to complete recovery, when apparently hopeless before, or go on 
to a fatal termination after a very short period of remission. 

The course of the disease is variable, usually under a year. 

Diagnosis. The general appearance of the patient is always 
suggestive of the form of anemia present. In no other form is 
the pallor or anemia as intense, but without careful and repeated 
blood examination a diagnosis is not justified. The group of 
symptoms enumerated above, with the characteristic blood find- 
ings, make a diagnosis certain. These important changes are 
a marked decrease in the red cells, to 1,500,000 or below, and 
an increase in their size; diminished number of white cells; 
slight relative decrease in hemoglobin ; presence of megaloblasts 
in increased numbers. 

Prognosis is graver, though apparently hopeless cases have 
recovered after a period of remission. If it is a bothriocephalus 
anemia, and the anemia improves, the prognosis is very good. 
The nearer the red cells decrease to 1,000,000 the graver the 
prognosis. 

Treatment. The removal of the bothriocephalus latus, if it 
or its eggs can be demonstrated, is the first indication. Felix 
mas is perhaps the most efficacious anthelmintic in this form. 

Special attention should be given the stomach and intestine 
by regulating the diet controlling diarrhea, if present, and the 
administration of remedies to limit the fermentation, bismuth 
and salol are especially efficacious. Constipation, if present, 
can be controlled by enemata. 

Arsenic is the remedy which gives the best results. It should 
be given in small initial doses, gradually increasing until the 
full physiologic effects have been noticed. The dose should 
then be decreased 20 per cent, and its administration continued 



450 THE DISEASES OF CHILDREN 

for several weeks at that dose. Fowler's solution is the best 
form for administration. 

The employment of direct transfusion of blood offers much, 
and should be used when possible. 

The patient should be given every opportunity to rally as 
regards his surroundings, climate, rest, freedom from work and 
worry, and during a remission extra precautions taken in these 
details. 

CHLOEOSIS. 

Definition. A primary anemia which occurs in girls about 
the age of puberty. There is an anemia, with diminished num- 
ber of red cells and hemoglobin. 

Etiology. It can be said practically that chlorosis occurs only 
in girls, and it is most frequent at puberty, from the twelfth 
to the eighteenth year. Often a history of chlorosis in the 
mother, or members of her family, can be brought out, or a 
tuberculosis in the family. A chronic intestinal indigestion 
and putrefaction, causing an autointoxication, may be a cause. 
Bad hygienic surroundings and crowded dormitories with insuf- 
ficient ventilation may be a predisposing cause. Constipation, 
improper food, lack of proper exercise and tight lacing and the 
changes incident to puberty are given as causes. 

Pathology. The chief changes occurring in the blood are as 
follows : The Jiemoglohin is reduced to a decided extent, reach- 
ing as low, in some isolated cases, as 20 per cent, the average 
being about 40 per cent; the number of red cells are reduced, 
but not to the same extent as indicated by the reduction of the 
hemoglobin. The average number of red cells is about 4,000,- 
000. They are pale, not deformed, but apt to be smaller than 
normal. Poikilocytosis is present in severe cases. 

The white cells may be normal in number. 

The specific gravity is reduced. 

Symptoms. The first symptom noted may be a disinclination 
to exercise in a previously active girl, palpitation, short, quick 



DISEASES OF THE BLOOD 451 

breathing or dyspnea, on going up the steps, dizziness, followed 
in a varying time by pallor of the skin and mucous membranes, 
the skin having frequently a greenish tinge. 

The changes in menstruation are more or less constant; in 
the majority of cases it is absent entirely, if present it is very 
irregular as to time and quantity of flow. This irregularity of 
menstruation m^y be the first symptom noted. Pain before or 
early in the stage of flow may develop. Leucorrhea is very 
often present. The appetite is poor and often capricious, crav- 
ings for acids is often a feature. Headaches are common, and 
are often associated with ringing in the ears. The circulation 
is poor, hands and feet cold. Blowing systolic murmurs are 
often heard, at various parts of the precordia, and a venous 
hum, the hridt de diahle, develops over the large vessels in the 
neck. 

~^o great changes are found in the urine. There may be an 
increase with low specific gravity. The spleen may be enlarged, 
but not markedly so. Hysteria may be seen in the specially 
neurotic girl. The duration is variable, usually, however, run- 
ning for several weeks. 

Diagnosis. The principal diagnostic features are the sex, 
age, anemia and blood findings, viz., marked diminution in 
hemoglobin, without corresponding diminution in the number 
of red cells, rapid improvement under proper treatment. 

Prognosis. Influenced greatly by the period of recognition 
and time of beginning treatment. 

Treatment. All girls at puberty should receive careful atten- 
tion. Rest at menstrual epochs, and carefully regulated diet 
and exercise is very important. The articles of diet specially 
indicated are the fats, vegetables and fruits. Those vegetables 
containing a large supply of iron are best, as the green vege- 
tables, spinach, etc. A change from the city to the country is 
also of great benefit as a prophylactic. 

At the first sign of anemia or the preliminary symptoms of 
chlorosis the girl should be taken from school, or a very care- 



452 THE DISEASES OF CHILDREN 

fully graded course outlined m connection with baths, diet, 
exercise and regulation of the bowels. The medicinal treatment 
is largely symptomatic, except the positive indication f oi the 
administration of iron. 

The bowels must be regulated by mild laxatives, cascara 
sagrada, aloin, belladonna and strychnia, etc., and other symp- 
toms treated as they arise. 

Iron must be given in some form ; metallic iron ; ferrous and 
ferric salts ; albuminates and peptonates ; nucleoalbumin prepa- 
rations. 

Diastiron is very assimilable and easily taken care of by most 
children. It can be given in a half to one teaspoonful, initial 
dose, gradually increased to two teaspoonsful. 

Pil Blaud is an excellent method of administration, beginning 
with one after each meal, gradually increasing during the sec- 
ond week to two after each meal, then decreasing to the original 
dose after a week. The following prescriptions are often found 
of service: 

I^ Tincture f erri chloridi f . 5 ss 

Acidi phosphorici diluti f. 3vi 

Spiritus limonis f . 3 ii 

Syrupi simplicis q. s. ad f. 5 vi 

M. Sig. Dessertspoonful in water after eating. 

I^ Acidi phosphor, dil. 
Acidi nitro-mur. dil. 
Acidi sulphurici aromat. 
Tr. ferri chloridi aa f. Bss 

M. Sig. Twenty drops in half glass of water. 

Iron should not be continued indefinitely, nor should it be 
given when no improvement in general symptoms or hemo- 
globin has been obtained in a short time, or where it produces 
decidedly bad symptoms with the digestive organs. One rem- 
edy which can be used to advantage in chlorosis is arsenic. The 
following pill is of service: 



DISEASES OF THE BLOOD 453 

I^ Ferri reducti gr. Ixxv 

Acidi arseniosi gr. iii 

Ext. glycyrrhizse q. s. 
M. et ft. pil No. C. 
Sig, One to four pills daily. (V. Noorden) 

LYMPHATIC LEUKEMIA. 

Definition. In this disease the characteristic symptom is a 
great increase in the number of leucocytes, with an increase in 
size of those organs specially associated with blood-making, 
spleen and glands. 

Two forms are recognized, the acute, in which there is a 
rapid and fatal termination in a few weeks, and the chronic j 
which may continue for months. 

The Acute Form. Etiology. Two types are recognized, the 
myeloid, in which there is great hypertrophy of the spleen and 
bone-marrow changes, and but little lymphatic enlargement, or 
the lymphoid, in which there is generally a hyperplasia of the 
lymph nodes, and in which the blood shows particularly the 
lymphocytes. 

Leukemia may occur at any age. Heredity is a causative 
factor. Among the other predisposing causes may be men- 
tioned intestinal intoxication ; poor surroundings and hygiene ; 
malaria; syphilis; tuberculosis; influenza and rachitis. 

Pathology. The Myeloid Form. The essential changes are 
in the blood, bone marrow and spleen. The red cells are slightly 
dirainished in number, averaging about 3,500,000. The hemo- 
globin is diminished probably to 50. The red cells show many 
nucleated forms. The typical changes in the blood are in the 
white blood corpuscles. The leucocytes are greatly increased 
in number, varying from 100,000 to 300,000, though there may 
be a far greater increase. 

The myelocytes are greatly increased in number. They may 
comprise more than one-third of the number of cells, and from 
this feature alone the diagnosis can be made. Polymorphonu- 



454 THE DISEASES OF CHILDREN 

clear cells are slightly increased in number, both large and 
smail, with nuclei staining differently. Lymphocytes are 
decreased quite decidedly, but not as much so as the myelocyte. 

The glands show cell proliferation and enlargement. 

Hemorrhages are of frequent occurrence, both on mucous 
surfaces and skin, and ulceration takes place in these areas. 
They may occur in the glands also. 

The bone marrow is changed from the normal fat marrow 
to a dark, wine-colored, soft marrow. 

Lymphatic deposit occurs in the spleen, liver, kidneys, esoph- 
agus, stomach and intestine, tonsils and thymus, all of which 
show enlargement or thickening. 

Symptoms. The course of acute leukemia is short, from a 
few days to several weeks, rarely lasting months. The onset is 
usually insidious, but it may be sudden, or at least few symp- 
toms are present while the preliminary blood changes are occur- 
ring:, which the patient will complain of. 

Lassitude, weakness, dizziness, headache, may precede the 
actual symptoms. This is followed by pallor of the skin and 
mucous membranes, and shortly by enlargement of the lymph 
nodes, spleen and tonsils. The spleen, when enlarged, is pal- 
pable. Hemorrhages occur in the skin, mucous membrane and 
in the eye. The hemorrhages in the skin may be simply 
petechise or large bruise-like areas. These also occur in the 
mucous membrane of the mouth, gums and palate, ^asal hemor- 
rhages may occur. !N'ecroses may develop at the site of these 
hemorrhagic areas. Hematemesis and hemorrhage from the 
bowel may be seen, and these active hemorrhages may cause 
death. 

Diagnosis. The blood changes are typical of the disease. In 
no other condition is a lymphocytosis so marked. 

Prognosis. This is unusually grave. Hemorrhages and septic 
infection at the site of necrosis may hasten the end. 



DISEASES OF THE BLOOD 455 

Treatment is of little avail and is largely symptomatic. Good 
food, stimulation when indicated, fresh air, the best surround- 
ings and administration of iron. 

The Chronic Form. In this class are included those rare forms 
in which the duration is longer than a few weeks. They present 
the same general symptoms and blood findings. 

Etiology. !N'othing definite is known of the etiology of this 
or the myelogenous form of leukemia ; of late some interesting 
suggestions have been made that it was probably the result of 
an infection. 

Pathology. The chief change is in the lymph nodes. The 
o'lands of the neck and thorax are principally enlarged. They 
may be soft and tender. The spleen is enlarged, in some cases 
to a considerable size. The bone marrow is reddish in color and 
of jelly-like consistency. The liver is enlarged, as are the ton- 
sils. Tumors form in the skin, generally quite small and shot- 
like, but they may enlarge to considerable size. 

Symptoms. The onset is usually gradual. It is often chronic 
in form. The anemia may precede liie enlargement of the lymph 
nodes or vice versa. The glands of the neck usually show the 
greatest proliferation and enlargement, with smaller ones in 
the axilla and groin. The spleen shows a regular onlargement. 

The blo^d shows a lymphocytosis. Of the increase in leu- 
cocytep, 90 per cent of them will be lymphocytes. The average 
ratio of white to red cells i= about 1 :50. The lymphocytes are 
usually of the small variety, under 10 /x in diameter, in the 
chronic form, and larger in the acute form. The red cells are 
reduced to 3,500,000, or lower, and the white cells, 300,000. 
Eosinophiles or myelocytes are very scanty or absent. Hemo- 
globin is decreased. 

Hemorrhages are infrequent. 

Dyspnea is a frequent and early symptom, which is due 
partly to blood changes, and chiefly to obstruction from enlarged 
lymph nodes. 



456 THE DISEASES OF CHILDKEN 

Diagnosis. The presence of the lymphocytosis is the chief 
diagnostic sign. In the presence of anemia, enlargement of 
lymph nodes and spleen, the blood should always be examined. 

Prognosis. The progress of this disease is toward a fatal 
termination, though it may last for months. 

Treatment. Practically nothing can be done in this form, as 
in the myeloid form, except to care for the case symptomatically. 

If there are pressure symptoms from the glandular enlarge- 
ment in the neck, surgery is indicated for relief, if the general 
condition is fairly good. Arsenic is indicated and should be 
given as early as possible. 

PSEUDOLEUKEMIA. 

Synonyms. HodyJcins disease; lymphoma. 

Definition. This is a primary disease of the lymph struc- 
tures. There is an enlargement of the lymph glands and spleen, 
much as in lymphatic leukemia, but without the blood changes 
in the latter. 

Pathology. Early in the disease the blood may be normal, but 
the hemoglobin decreases as it progresses, and there is a decided 
anemia. At first there may be no change in the white cells, but 
later there is a marked increase in the white cells, a ratio being 
sometimes seen (in the presence of adenitis) of 1:80 when 
compared to the red cells. The increase is chiefly in the 
lymphocytes. 

The red cells are progressively diminished in number. 

Symptoms. The chief symptoms are those pointing to the 
lymph glands. These may be hard or soft. The spleen is reg- 
ularly found enlarged. The glands of the neck show the great- 
est enlargement. With the progress of the anemia the consti- 
tutional symptoms develop, weakness, dizziness, fainting, palpi- 
tation, etc. Skin tumors develop as in lymphatic leukemia. 
Its course is slow and death may occur from pressure on the 
vessels of the neck and on the trachea and bronchi. 



DISEASES OF THE BLOOD 457 

Diagnosis. The enlargement of the lymph nodes, with blood 
changes, showing lymphocytosis, a relative increase of 1:200 
ratio of white to red. The diagnosis must be made from a 
glandular tuberculosis, in which there will not be any of the 
typical blood changes, and from lymphosarcoma, in which the 
lymph glands show malignant change and the blood changes are 
not those of pseudoleukemia. 

Prognosis. Death is not as prompt as in leukemia, but just 
as certain in time. There is no cure. 

Treatment. Apparent improvement has been reported from 
the use of arsenic and the iodides. Surgery is not to be recom- 
mended. In the large growths about the neck, some good may 
be accomplished by the use of the X-ray^ 

PSEUDOLEUKEMIA OF INFANTS. 

Synonyms. Anemia pseudoleuhemic infantum (v. JaJcsch) j 
pseudopernicious anemia (EJirlicli). 

Definition. This is a gTave form- of anemia, first described 
by V. Jaksch in 1889. There is a severe anemia, leucocytosis 
and enlargement of the lymph nodes, spleen and tonsils. 

Etiology. It may occur independently or develop from some 
of the grave anemias. It occurs between the seventh and ninth 
month and the fourth year. 

Pathology. The chief change is an enlargement to consid- 
erable size of the spleen, which can be seen through the abdom- 
inal wall. It is hard to the feel. The liver is slightly but not 
markedly enlarged. The lymph nodes are quite regularly 
enlarged, but not to the size seen in typical pseudoleukemia. 

The blood show^s a marked diminution in the hemoglobin, 
often considerably below 50. There is a regular decrease in the 
red blood cells, to 2,000,000 or below. ISTucleated red cells are 
found, megaloblasts and normoblasts. 

The white cells are increased, myelocytes are found. They 
stain irregularly. 



458 THE DISEASES OF CHILDREN 

Symptoms. There are no typical symptoms. Those common 
to the other types of anemia are present. . There is generally a 
loss of appetite ; enlargement of glands and spleen ; emaciation, 
with a tendency to develop into a chronic condition. Without 
a clear history of syphilis, this may be suspected instead of 
the anemia. 

Treatment. The administration of iron and arsenic and the 
careful regulation of the feeding are the most important indi- 
cations to be met. 

In older children a rich proteid diet is best; meat, eggs and 
milk; in the younger a fat increase should be made and con- 
tinued as long as well borne. 

PURPURA. 

Definition. This is a condition characterized by hemorrhages 
occurring under the skin and from the mucous membranes. 

Etiology. It is divided into two varieties, purpura simplex, 
the bleeding being limited to the skin, and purpura Jiemor- 
rJiagica, where there are hemorrhages into the internal organs 
and from the mucous membranes. 

It may be due to septic conditions and the infectious dis- 
eases, as septic endocarditis and the exanthemata; as a result 
of exhausting diseases, as bronchopneumonia, pertussis, typhoid 
fever, ileocolitis, tuberculosis ; from the administration of cer- 
tain drugs, as phosphorus, quinine, salicylic acid, arsenic, bella- 
donna, etc. ; or it may occur without any apparent cause. It 
occurs chiefly under 10 years of age. 

Pathology. !N'o definite pathology is knoT\m, except there is 
an endarteritis, without characteristic changes in the blood. 
Hemorrhages occur in the interual organs, chiefly the supra- 
renal capsules. 

Symptoms. In the ordinary form a purpura simplex, after 
a day or so of indisposition, perhaps some indigestiori, a number 
of petechial spots appear upon the skin, chiefly at first upon 



DISEASES OF THE BLOOD 459 

the lower extremities and buttocks, and finally generally upon 
the whole body. Later there may be larger areas of extravasa- 
tion, large, bruise-like spots. As the hemorrhage is absorbed 
it leaves a bluish-black discoloration. ISTot infrequently some 
fever is seen, to 100° F., or slightly more. 

Prognosis. Recovery usually takes place in this form, but 
relapses are common and a guarded prognosis should always be 
given. 

Purpura hemorrhagica (also called morbus maculosus, Werl- 
hoff's disease). 

In this form, besides the skin hemorrhages, petechial and 
ecchymotic, there are hemorrhages into and from the mucous 
membranes, hematemesis and bloody stools, nosebleed (the most 
common) and exophthalmos, caused by orbital hemorrhage. 
The skin hemorrhages are more numerous. Joint pains, due to 
hemorrhages into them, are common. There are some consti- 
tutional symptoms, temperature from 101° F. to 103° F., with 
prostration, dry tongue and mouth, the patient falling into the 
typhoid type. 

Where the case progresses rapidly and is quickly fatal it is 
referred to as purpura fulminans. 

Henoch's Purpura. In this form there are three groups of 
symptoms described. Skin, presenting the hemorrhages, pete- 
chial and ecchymotic, besides urticaria, and perhaps an edema ; 
the joints, swelling and pain in these being present, one or 
more ; and the visceral symptoms, consisting of colic, diarilaea 
and vomiting, the passage of blood both ways. In addition 
there may be hematuria. 

The tendency in this form is to be apparently entirely 
relieved, with recurrences over a period lasting perhaps several 
years. 

Purpura rheumatica is the occurrence of hemorrhages in the 
skin in an attack of rheumatism. There are enlarged and pain- 
ful joints, with frequent endocardial involvement, temperature, 
erythema nodosum, etc. 



460 THE DISEASES OF CHILDEEN 

Prognosis depends upon tlie form of purpura. In the simple 
form it is good, with tendency to relapses; in the hemoiThagic 
form, where the bleeding is not profuse, the child may recover. 
In the fulminans type it is rapidly fatal ; in Henoch/ s purpura 
recoveries are rare, where it has recurred frequently. 

Treatment. In all varieties the child should be put to bed 
and kept there until all symptoms are relieved. An antiscor- 
butic diet should be given, in which fruit juices and fresh milk 
and vegetables are given. Ergot has been tried without suc- 
cess. If the hemorrhage is profuse, subcutaneous injection of 
gelatine solution should be tried. Adrenalin hypodermically 
can also be used. Iron and tonics are indicated in convalescence. 

HEMOPHILIA. 

Definition. This is an hereditary disease in which there is 
a tendency to severe bleeding from any surface, from a very 
slight abrasion. One so affected is called a ''bleeder." 

Etiology. The hereditary tendency in typical cases is quite 
marked, and may be traced through several generations, with 
one or more of each family similarly affected. Males are often er 
affected than females, but the transmission of the tendency is 
more often through the female side of the family, though she 
may herself escape it. Even though herself healthy, and mar- 
ried to a healthy man, their male offspring are liable to 
develop it. 

Eace may play a part. It is frequent in the Jews. It may 
develop in early infancy or be delayed until after the eruption 
of the deciduous teeth. 

Pathology. This is unknown, perhaps an endarteritis or a 
thinning of the vessel walls. 

Symptoms. The condition may go unrecognized until a bleed- 
ing occurs from an apparently trivial cut or abrasion, which 
assumes an alarming proportion quickly. If an abrasion it may 
be an oozing, which pressure or other hemostatic measures 
ordinarily used does not stop. The bleeding may occur from the 



DISEASES OF THE BLOOD 461 

mucous membranes, especially the nose, following trauma, into 
the skin or joints. A mere scratch, the pulling of a tooth, the 
cutting of a tooth in an infant, may cause severe and dangerous 
bleeding. 

Diagnosis. This can be made from the amount of hemor- 
rhage which follows a trivial abrasion, cut or trauma, and the 
distinct hereditary history. 

Prognosis. These children, if the case is a decided one, rarely 
live to puberty ; should they pass this period the chance of death 
being caused from hemophilia grows less and less. There is 
no great tendency to increased bleeding in females at menstrua- 
tion or postpartum. 

Treatment. Prophylaxis is the main consideration. Pre- 
vention of cuts and trauma, but if trauma should occur the 
hemorrhage should be stopped as quickly as possible. Styptics 
are not of very great benefit but should be tried, perchloride of 
iron, tannic acid or adrenalin may be used. Rest in bed should 
be insisted upon. Operations should not be performed, espe- 
cially tonsillotomy and removal ~ of adenoids. Adrenalin 
(1/1000, 5 or 10 min.) ergot, liquor ferri chloridi (20 min.) 
can be used internally. Fuller recommends the use of thyroid 
extract 



CHAPTER XIX. 
Diseases of the Lymphatic Glands. 

The lymph nodes are very prone to develop hyperplastic proc- 
esses during infancy. Any group of glands may enlarge, or 
there may be a general enlargement of all of them. 

THE THYMUS GLAND. 

But little definite is known of the function of this gland. It 
is quite regularly enlarged in the infant, and to it have been 
ascribed sudden deaths occurring without apparent cause in 
cases in which it was found to be enlarged. 

It is found to extend from slightly above the sternal notch 
to the third or fourth costal cartilage, and may be 2 inches or 
more in width, and it may weigh from ^ to 2 ounces. 

In cases of sudden death due to enlarged thymus, there is 
nothing else found at autopsy which can be looked upon as a 
cause. The only symptom which may be present is a sudden 
lividity, or cyanosis, followed by death. Direct pressure of the 
gland upon the trachea or the recurrent laryngeal or vagus 
nerve may be the cause of the death. 

Xo treatment is of avail. 

The thymus is best outlined by percussion, showing as a 
triangular area of dulness, irregular in outline, its base at the 
sternoclavicular margin and the apex at the second rib. The 
sides of the triangle extend slightly beyond the margin of the 
sternum, a little more so on the left than the right. The thymus 
and precordial area of dulness may coalesce. 

In children with an enlarged thymus, a condition of statics 
lympliaticus exists. The subjects are pale, anemic and pasty 
in appearance, and in older children, especially girls, the symp- 
toms are thof=c of a chlorosis. There is usually a general enlarge- 

462 



DISEASES OF THE LYMPHATIC GLANDS 463 

ment of the superficial lymph nodes. They have but little 
resistance to infectious diseases, and are frequently affected 
with tonsillitis and bronchitis. Sudden death in these children 
is not rare, especially as a result of a general anesthetic, more 
especially chloroform. The death may occur after the first 
few inhalations during the operation or after the removal of 
the cone. This should always be borne in mind before an anes- 
thetic is given, when a diagnosis of this condition of status 
lymphaticus is made. 

ACUTE ADENITIS. 

Definition. An acute inflammation of the lymph nodes, local 
or general. 

Etiology. This condition is secondary to an inflammation 
of adjacent structures, skin or mucous membrane. The extent 
of the inflammation and number of glands involved depends on 
the extent of area of skin or membrane involved in the intiarn- 
mation. The bronchial ijuiph nodes may be primarily involved 
from tubercular invasion, by direct absorption of the bacilli 
from the broucliial liiiieous iiieinbi'ane or the intestine. 

^Mese'iiiciio enlargement occurs from absorption of tubercle 
bacilli and from acute inflammatory conditions of the intestinal 
tract. 

Inflammations of the mucous membrane of the nose and 
throat, of the mouth and of the scalp, may cause a cervical 
adenitis. Vaccination upon the leg may cause a severe inflam- 
mation of the inguinal glands. 

Pathology. There is an acute congestion of the gland with 
hyperplasia of the lymphoid structure. If there is direct inva- 
sion of the pus-producing organisms, a softening and breaking 
down of the gland usually occurs. 

Symptoms. When secondary to other conditions, there is a 
rise in temperature, with swelling and painful glands. If it 
is severe, redness of the skin over it develops, and it becomes 
quite tender and painful. An adjacent cellulitis may develop. 



464 THE DISEASES O^ CHILDREN 

Without suppuration the gland may remain firm and hard as 
long as the inflammation of the adjacent structures continues, 
and upon its relief the gland subsides. 

A relapse of the cause will again cause enlargement of the 
glands. 

Prognosis. Eecovery follows, but not always without sup- 
puration and destruction of the gland. In marasmic and cachec- 
tic children the condition is apt to develop into the chronic form. 

Treatment. The cause must be sought and removed, disease 
of the scalp and the mucous membrane treated. 

Locally much good can be accomplished in the acute cases, 
without apparent pus formation, by the application of 50 per 
cent grain alcohol poultices on absorbent gauze, protected by 
rubber tissue, or the application of pure ichthyol. Mud poul- 
tices do no good, save to hold the part fixed, thus saving pain. 

When much redness of the skin takes place and an area of 
softening, indicating pus formation, a free incision should be 
made and the gland drained. 

Where they remain enlarged after subsidence of the con- 
tiguous inflammation, iodine in some form should be adminis- 
tered, the iodide of iron or hydriodic acid being beneficial. 

CHRONIC ADENITIS. 

This condition, in which there is a chronic inflammation and 
hyperplasia of the lymph nodes, usually follows an acute attack 
of inflammation. It may occur coincidently with a long-stand- 
ing and chronic inflammation of the skin, as an eczema of the 
scalp, or of the mucous membranes of the nasopharynx and 
pharynx. 

Symptoms. The chief symptoms are the presence of enlarged 
glands, superficially situated about the body, as at the back of 
the neck, in the axilla and in the groin. These glands or groups 
of glands are hard, not tender, and show no tendency to break 
down or suppurate. The tendency is for them to remain sta- 



DISEASES OP THE LYMPHATIC GLANDS 465 

tionary for some time, perhaps months, and then to gradually 
become smaller. The process is simply one of a hyperplasia of 
the connective tissue without inflammation. There is no fever 
or inconvenience suffered by the child. It occurs most often 
under 10 years of age. 

Diagnosis. If the glands assume some size the condition 
becomes suspicious of a general blood trouble, as Hodgkin's 
disease, or perhaps tuberculosis may be suspected. 

Treatment. Remove or alleviate the cause. If a skin lesion 
treat it properly; if there are chronically enlarged tonsils or 
adenoids they should be removed; the nose should also receive 
attention. Potassium iodide is of great service in the form of 
syrup of the iodide of iron or hydriodic acid. Cod liver oil, 
not the extracts of the oil, given in the cool months, is of great 
benefit. Good and nourishing food must be given, change of 
surroundings, perhaps of climate, may be indicated. 

Addison's disease. 

This is quite a rare disease in children. Comby has selected 
21 cases in literature; practically never seen under 10 years 
of age. 

It is characterized by the same train of symptoms as seen in 
adults, viz., bronzing of the skin, which is due to a deposit of 
pigment in the malpighian layer, progressive weakness of gen- 
eral muscular system and pulse, and gastrointestinal symptoms, 
as vomiting and diarrhea. The bronzing is chiefly of the 
exposed parts of the body, though the rest of the body may be 
as deeply pigmented. 

Pathology. The chief change is a tuberculosis of the adrenal 
glands, with later tuberculosis in other organs, lungs, spleen, 
liver and glands. 

Diagnosis. Pigmentation of skin from arsenic and exposure 
must be borne in mind; neither are attended with the general 
symptoms referred to. 

Prognosis. This is always grave. 



466 THE DISEASES OP CHlLDfiEN 

Treatment. Tonic and supportive treatment is indicated. 
From the location of the chief lesion, the suprarenals, adrenalin 
may be tried, given in 2 or 3 drops of 1 : 1000 solution. Symp- 
tomatic treatment must be carried out. 

CKETII^ISM. MYXEDEMA. 

Definition. This is a condition which evidences itself by a 
remarkable backAvardness of the child in its growth, of body and 
mind, an abundance of deposit of fat or mucin out of pro- 
portion to its bodily growth; in other words a persistence of 
infantilism. 

Etiology. E"othing very definite is knov^m of the cause. It 
has long been known to be prevalent in certain mountainous 
and limestone districts of Switzerland. This is looked on as 
the endemic form. Sporadic cases develop in any country, and 
a number have been reported in the United States. 

The thyroid gland is supposed to be at fault, an insufficient 
secretion being the cause. It may follow the exanthemata, 
though just what the connection between them is we do not know. 

Pathology. The thyroid gland is usually atrophied, or there 
may rarely be an enlargement, a goitre. Ossification is delayed. 

Symptoms. There is no regularity in regard to the onset. It 
is usually insidious, coming on as a rule after the second year, 
but may appear soon after birth. These cases have the appear- 
ance of a dwarf, the extremities are short, the body apparently 
too large. The face is expressionless and idiotic when the 
tongue protrudes from the mouth. The mouth is constantly 
open, and there is constantly a flow of saliva. The eyes are 
expressionless and the eyelids baggy. The teeth are cut late, 
are irregular in shape and decay quickly. There is an anterior 
curvature of the spine. The temperature is usually below nor- 
mal, the skin baggy, harsh, cold and quite anemic and pale. 
The face is expressionless and the child apparently has no 
intellection whatever. The broadening of the base of the nose 
is characteristic. The fontanelles, especially the anterior, are 



DISEASES OF THE GENITO-UKINARY SYSTEM 467 

apt to be open. There is a "pot belly," wMcli is quite marked. 
They -asually show no sign of talking, and sounds made are 
harsh and unnatural. They may be able to stand, and if urged, 
to take a few steps, but usually show no signs of or inclination 
to walk. Other cretins may be in the family, usually, however, 
other children are normal. 

Diagnosis. A mental picture of this condition should make 
diagnosis easy. From Mongolian idiocy the diagnosis may not 
be so easily made. In the latter there is the Mongolian facies, 
they are more intelligent and not so deformed, the skin is not 
thickened, and the bridge of the nose not so wide. In this form 
the characteristic curving inward of the tip of the little finger 
is generally seen. Other conditions may be confounded, as 
infantilism, in which the infantile expression and size are main- 
tained, with an atrophy of the genitalia. The skin is soft but 
dry, and appendages unhealthy ; the mind is infantile also. 

Infantilism of the Lorain type* is described as a condition 
in which there is an imperfect development of the arterial sys- 
tem, causing insufficient nourishment. There is a premature 
ossification and stunted growth. A skiagraph of the hand shows 
ossification complete, while in myxedema there is a deficiency 
in the appearance of the nuclei of the carpal bones, and a failure 
of phalanges and metacarpals to unite. Thyroid treatment in 
this class of cases is unavailing. 

Pro^osis. These cases, if unrecognized and untreated, may 
live considerably beyond puberty, but maintain the idiotic look 
and mind, and dwarfed body. The earlier the cases are recog- 
nized and treatment begun, the results are quite brilliant. Good 
results have been reported when treatment has begim after 
puberty. 

Treatment. As stated, the treatment of cretinism is brilliant 
in its results. Thyroid extract given internally quickly restores 
the child to normal. Thyroid extract can be given in tablet 
form. 4 to 3 grains at a dose at first, increased to 5 grains at 

* Meige: Gaz. des Hdp., 1902. 



468 THE DISEASES OF CHILDREN 

a dose, three times a day. To infants, J gr. or -J gr. should 
be given at first, gradually increasing to 1 or 2 grains. The 
thyroid should be given over a long period of time, at least 
four or five months, the dose then being given less often, with 
a few days' rest between. 

The first improvement occurs in a week or so, and is in the 
facial expression. The tongue no longer appears too large for 
the mouth, the skin loses its myxedematous feel and appearance, 
the hair looks more natural, delayed teething takes place, the 
mental condition seems to quickly assume its proper pro- 
portions. 

After the discontinuance of the regular dose of thyroid for 
several weeks, it is again given once or twice a week for several 
months, and for a long time the child should be kept under 
observation and the thyroid again given if indications of, mental 
dulness or sluggishness again appear. 



CHAPTEE XX. 

Diseases of the Gen-ito-ukinaky System. 

THE upj:ne. 

The urine of a healthy infant should be nearly colorless, 
should not stain the napkin, and of a low specific gravity, from 
1004 to 1010. In the new-born the amount passed is much 
less than in older children, during the first 24 hours, probably 
not averaging more than an ounce. During this time there is 
apt to be a relatively large amount of the salts of urea, which 
appears as a very fine sand, and the urine is much thicker than 
normal. The uric acid may collect as infarcts in the kidney and 
cause a suppression of urine until dislodged and washed out. 
The failure to pass urine during the first 24 hours is an indica- 
tion for the administration of water, both by the mouth and 
the bowel, to thoroughly fiush the kidneys. 

Uric acid remains relatively large in amount in proportion 
to the other urinary constituents during childhood. 

It is often difiicult to obtain a sample of urine from an infant 
for examination, and next to impossible to obtain a 24-hour 
specimen. In male infants, by attaching a rubber condom to 
the genital organs, including scrotum and penis in the neck of 
the rubber, and fastening by tapes around the waist, enough 
urine for a chemical and microscopic examination can easily 
be obtained. In girl babies this is often much more difficult. 
The appliances suggested by Chapin is a most useful one, and 
can be applied to the vulva and retained by tapes tied to the 
thighs or waist and worn without discomfort until the sample 
needed is obtained. The end of the urinal is put in a bottle, 
or a rubber tube attached, and its free end placed in a bottle. 

Placing the child upon a rubber sheet without napkin or pro- 
tective dressing, or placing a sterile sponge or piece of gauze 



470 THE DISEASES OF CHILDREN 

over the vulva or the penis, which as soon as wet is squeezed 
into a test tube, later filtered, may be successful if persisted in 
long enough. 

The difficulty attending the obtaining of a sample of urine 
has unquestionably been the cause of neglect in the examina- 
tion of the urine of infants in the past, but even if catheteriza- 
tion must be resorted to in order to obtain a specimen for exam- 
ination, it should be done. Many obscure cases can be cleared 
up if the urine is examined, and too great emphasis cannot 
be laid upon it. 

During the third month it is estimated 200 cc. of urine is 
passed with a specific gravity from 1004 to 1010, and from 
1 to 2 grams of urea; during the sixth month, 250 cc. of urine; 
specific gravity, 1006 to 1012 ; during the twelfth month, 400 cc. 
with 11 grams of urea ; from two to five years, 500 to 800 cc. ; 
five to eight years, 600 to 1200 cc. ; eight to 15 years, 1000 to 
1500 cc. The urine gradually increases in amount to 1000 
cc. in the tenth year, with a specific gravity of 1015, and 20 
grams of urea. 

ALBUMINURIA. 

Normal urine contains nucleoalbumin, but not serumalbumin, 
and when serumalbumin is present it should be considered 
abnormal, and the indication of pathologic conditions. Serum- 
albumin is sometimes, but not with any regularity, found in 
the urine of infants during the first week after birth, but its 
persistence is indicative of abnormalities, su.ch as nephritis, the 
ncute and chronic parenchymatous forms, pus in any organ or 
cavity, etc. 

Croftan* describes an intermittent albuminuria and a cyclic 
albuminuria. He gives as causes of the first, nervous influences, 
exposure to cold, diet and overexertion, and describes a dyspeptic 
albuminuria, which is present in intestinal disorders and dila- 
tation of the stomach. This form of albuminuria if continued 
for a long period learl= to true nephritis. 

* Crof tan: Clinical Urology. 



DISEASES OP THE GENITO-URINARY SYSTEM 471 

CYCLIC^ FUN^CTIONAL OR INTERMITTENT ALBUMINURIA. 

This condition is not infrequent in older children, about the 
age of pubertjj especially. As the name implies, albumin may 
be found in the urine during certain hours in the day, and at 
other times it is absent. 

Etiology. It is seen most often in boys. It has been thought 
to be due to severe and fatiguing exercise; cold and prolonged 
bathing ; exposure to cold ; continuing indigestion ; lithemia ; 
but Croftan believes only two factors are to be considered in its 
etiology, viz., changes in the position of the body and muscular 
fatigue. The theory of the postural cause is that the albumin- 
uria "is due to a certain reactive insufficiency of the circulatory 
apparatus," that it is a "manifestation of a vasomotor fatigue." 

Pathology. This form of trouble has no pathology, as there 
are no pathological changes. When an albuminuria is due to a 
change in the kidneys, the condition is no longer a functional 
trouble. 

Symptoms. Usually the albuminuria is discovered accident- 
ally, as the child may not present any symptoms. The chief 
and only symptom perhaps may be an indigestion, and if per- 
sistent long, an anemia. 

The urine does not show albumin continuously as indicated 
by the name given the trouble. 'No albumin may be present on 
arising, but by noon it is shown to some extent, and persists 
until night, when the amount gradually decreases, a prolonged 
stay and rest in bed may clear the urine entirely. An increase 
in the urinary salts may be seen, uric acid, urates and oxalates. 

Diagnosis. In every case of albuminuria the symptoms and 
urinary findings should be carefully weighed before a diagnosis 
is made. Frequent and careful chemical and microscopic exam- 
ination of the urine should be made to exclude a nephritis. The 
presence of casts in a centrifugalized specimen of urine is suffi- 
cient to exclude functional albuminuria. 

Prognosis. Where the diagnosis can be made positively the 
prognosis is favorable. 



472 THE DISEASES OF CHILDREN 

A persistent albuminuria should be regarded with suspicion, 
as indicative of organic changes in the kidney. 

Treatment. Eest in bed while the quantity of albumin is 
large, careful diet, limiting the amount of nitrogenous foods ; 
regular and graduated exercises, never to the point of fatigue, 
and not violent at any time. 

Occasional doses of calomel are of great benefit, with a mild 
saline following; and as suggested by Croftan* ''on the basis 
of the vasomotor fatigue theory, cardiac tonics are indicated, 
and good results have been obtained by this therapy." 

Change in climate may be necessary, to a warmer, more 
equable one. 

PYELITIS. 

Definition. An inflammation of the pelvis of the kidney. 
When the inflammation extends to the tubules of the kidney it 
is a pyelonephritis; when an accumulation of pus in the kidney 
takes place, a pyonephrosis. 

Primary and secondary pyelitis have been described, but it 
is difiicult to draw the line between the two. 

Etiology. The presence of a calculus in the pelvis of the 
kidney may act as an exciting cause. It occurs more frequently 
in female than in male infants, and is probably due to an exten- 
sion of bacilli from the vulva and vagina to the pelvis of the 
kidney without a coincident urethritis or cystitis. The chief 
infecting organism is the colon bacillus, gaining entrance direct 
from the intestinal tract. A diarrhea may precede the acute 
symptoms of the pyelitis. It occurs at any age, but in my 
experience most often in female infants between 6 and 18 
months of age. 

Symptoms. The onset is usually sudden and the symptoms 
obscure. The chief symptom is a persistent and irregular tem- 
perature, usually to 105° F., ushered in often with a chill or 
evidences of chilliness, manifested by blueness of the skin, cold 

* Loc. cit. 



DISEASES OF THE GENITO-URINARY SYSTEM 473 

hands and feet and feeble circulation. The temperature may 
show a decided remission or remain persistently high with but 
slight remissions. 

There may be a preceding gastrointestinal disturbance or vom- 
iting without any bowel disturbance. 

'No symptoms are present as a rule referable to the kidney, 
no tenderness or pain in the loin or abdomen. Unless the con- 
dition is recognized by a careful examination of the urine the 
case may continue indefinitely, showing a continuous tempera- 
ture, anorexia, emaciation, restlessness and profound anemia. 

The urine shows albumin and a microscopic examination, 
large numbers of pus cells. The urine is diminished in amount, 
is apt to be cloudy from the pus present, and kidney epithelia. 
The epithelia are from the kidney pelvis and the ureter. If the 
condition has existed long, hyaline casts may be found chiefly 
of large size. 

If the so-called secondary form of pyelitis in which a calculus 
is present, there is pain and tenderness, renal colic and blood 
in the urine. Bacteriological examination should be made in 
long-standing cases, looking especially for the tubercle bacillus. 

In one of my cases the microscopist reported the presence of 
foreign bodies resembling the ova of an intestinal parasite, and 
it was puzzling to several who saw it, until I recalled the fact 
that lycopodium powder was used on the buttocks, and the sus- 
pected ovum proved to be the seed pod of the lycopodium. 

Diagnosis. This is not always easy, but will be made much 
more readily and often if systematic examinations of the urine 
are made. Every case of sudden temperature, in which diseases 
of the gastrointestinal tract and lungs can be ruled out, if it is 
continuous, should be suspected, and a careful urinalysis made. 
The urinalysis is not complete without a microscopic examina- 
tion. Pus, kidney cells, albumin, and a highly acid urine make 
the diagnosis certain. 

Prognosis. In uncomplicated pyelitis the prognosis is good. 
It is influenced by the time which elapses between its onset 



474 THE DISEASES OF CHILDREN 

and the making of the diagnosis. Its course under treatment 
is usually about two weeks, and recovery is the rule. 

Treatment. Urotropin gives universally good results. It is 
given in 3 grain doses to a child of one year, every three hours, 
with as much water during the 24 hours as possible. 

If there is a complicating enterocolitis a preliminary dose of 
calomel and castor oil should be given, followed by a colon 
injection of normal salt solution, and a subsequent daily evacu- 
ation obtained. To neutralize the urinary acidity, Holt recom- 
mends potassium citrate, 2 or 3 grains, well diluted, every three 
hours. 

Unless there is a decided abnormal condition of the bowels, 
no change is made in the diet; milk, however, being preferred 
to any other article. 

RENAL CALCULUS. 

Synonym. Stone in the kidney. 

Etiology. Stone in the kidney in children is infrequent. 
They have their origin in uric acid, though they may contain 
oxalate of lime also. Large calculi are comparatively rare. 
Bacteria and cellular detritus in an inflammatory condition of 
the pelvis of the kidney may form the nidus for a stone. 

Symptoms. Small calculi, more like sand, may form in the 
pelvis of the kidney and be washed free into the ureter and 
bladder, and passed from the bladder with the urine. These 
frequently cause pain in their passage through the ureter, evi- 
denced by restlessness and crying, a diagnosis of the condition 
not being made until the sand or calculus is passed from the 
bladder and found on the napkin or in the vessel. In the male 
the passage of the sand through the urethra is attended with 
great pain, and if the child is large enough, referred to the end 
of the penis. I have seen one stone which had evidently lodged 
for some time in the glans portion of the urethra and grad- 
ually increased in size there, as it took exactly the shape of 
that portion of the urethra. An examination was made to ascer- 



DISEASES OF THE GENITO-URINARY SYSTEM 475 

tain the cause of the painful urination and this stone found, 
very slightly distending the meatus. It was fished out with a 
line hemostatic forceps and complete relief afforded. 

If the stone is retained in the pelvis of the kidney a pyelitis 
and pyonephrosis results. Absorption takes place, chills, sweats, 
wasting, prostration and great pain, caused by the effort to 
pass it on through the ureter, too small to receive it. 

Treatment. Renal colic is very painful and usually requires 
anodynes for its relief. Opium in some form is necessary, 
paregoric or the deodorized tincture, in the minimum dose, 
repeated if need be. Relaxation from a general hot bath is of 
service. Urotropin is of great service in cases with infection 
from pyelitis. In the presence of very great pain, sepsis, chills, 
etc., the condition becomes a surgical one, and early operation 
for drainage should be urged. 

Liberal water drinking in this condition is of the greatest 
benefit. 

PERINEPHKITIS. 

Definition. This is an inflammation of the connective tissue 
surrounding the kidney, with or without the formation of pus. 

Etiology. It may be 'primary, due to trauma, exposure and 
cold, or secondary, following the acute infectious diseases, pye- 
litis or pyonephrosis, or vertebral diseases. 

Pathology. The loose connective tissue surrounding the kid- 
neys undergoes inflammatory reaction with frequent localizing 
of the process and the formation of an abscess. 

Symptoms. The onset is sudden, with a decided chill and 
pain located in the lumbar region of the affected side. The pain 
is reflected along the psoas muscle to the inguinal region groin 
or the thigh. There is tenderness over the loin and pain is 
increased by walking or bending forward. 

There is a rise of temperature with septic symptoms and 
digestive disturbances, chiefly vomiting, in the acute cases. It 
may begin slowly with some pain and tenderness, increased on 



476 THE DISEASES OF CHILDREN 

movement. If the abscess forms the pus will travel toward the 
least resistance, may open on the skin, or follow the psoas 
muscle and open on the thigh. 

Diagnosis. This must be made from pyelitis. In peri- 
nephritis no pus cells in the urine; from hip-joint disease, by 
limited motion of leg, and atrophy of the muscles of the thigh. 

Treatment. Absolute rest in bed; light diet; anesthesia for 
the incision of the abscess sac, if it is thought advisable. An 
exploratory puncture can be utilized at any time. 

ACUTE PAKENCPIYMATOUS NEPHRITIS. 

Synonyms. Acute Bright' s disease; acute exudative neph- 
ritis; catarrhal nephritis; acute desquamative 7iephritis. 

Etiology. This form of nephritis may be primary or second- 
ary, but is more frequently secondary. Primary nephritis is 
rare. Holt has collected 24 cases from his practice and from 
literature. I have seen but one case in my own practice with 
recovery. Undue exposure is the most frequently reported cause 
of the primary form, though no cause may be found. 

The secondary form is generally due to one of the exanthemata 
or infectious diseases, scarlet fever and diphtheria being the 
most frequent causes. In various epidemics of scarlet fever 
the number of cases of complicating nephritis vary from 5 per 
cent to YO per cent. It may occur as a complication in septic 
conditions from any cause, notably the streptococcic infection 
in gastrointestinal infectious diseases, and other causes occur- 
ring much more frequently in older children. 

The active cause of the inflammatory condition of the kidney 
in the infectious diseases is the irritating effect of the toxins 
on the parenchyma of the kidneys. 

Pathology. The epithelia are degenerated, the kidney stroma 
infiltrated to such an extent that the kidney is enlarged and 
softened. The capsule is not adherent. The surface of the 
kidney is deeply injected, as are the pyramids on section. The 
tubules are dilated and contain blood cells and epithelia. 



DISEASES OF THE GENITO-URINARY SYSTEM 477 

Symptoms. Systemic. The onset is generally abrupt. In the 
very young uremic symptoms may be manifest early by the 
attack being ushered in by a convulsion; vomiting and some- 
times diarrhea are present early. There is a sharp rise of 
temperature, the pulse correspondingly rapid, and the tension 
quite high. Edema is present early, in the face, perhaps only 
the eyelids, the legs and thighs. Ocular symptoms may be 
present early, spots before the eyes or even blindness. Head- 
ache is prominent and anemia quickly appears. 

Focal. The urine is very scant, cloudy and high colored. 
The specific gravity is high, and albumin is present in consid- 
erable quantity, usually larger if the amount passed is small. 

Microscopically J all varieties of casts, large and small, are 
found, and free-blood cells also. If the urine is abundant, the 
casts may not be as numerous. 

In the secondary form the symptoms usually present late in 
the disease. After having been afebrile the temperature begins 
again, it is more irregular, and not quite so high, the child 
quickly appears sick again, after an apparently satisfactory 
convalescence. There is vomiting, headache, restlessness, edema, 
and much the same urinary symptoms as in the primary form. 

The duration in the primary form is from two or three days 
to two weeks, and in the secondary form a slightly longer period. 

An improvement is first noticed in the amount of urine passed, 
with gradual improvement in all the symptoms. 

Prognosis. The younger the children the graver the prog- 
nosis. Either form of nephritis is very serious in the young. 
Albumin and casts may both persist for some time after the 
acute symptoms subside. 

Treatment. Prophylaxis. During the infectious diseases, 
prevention from exposure to cold; a carefully regulated diet in 
which milk should predominate; regular actions from bowels; 
plenty of water to flush the kidneys; keep the skin active by 
warm baths. Close confinement to bed in these infectious cases 
may often prevent kidney involvement. 



478 THE DISEASES OF CHILDREN 

Management. Diagnosis having been made, active treatment 
must begin with promptness. The following indications are to 
be met : (a) Relieve kidneys of the extra work of draining the 
serum from the tissues, as well as from excreting the retained 
products of tissue metamorphosis; (6) restore the kidney to its 
normal condition; (c) by careful and intelligent medication and 
diet prevent further damage to the diseased organs; (d) rest 
in bed. 

Diet. The bulk of the diet, though not exclusively, should 
be milk, whole, or in the form of buttermilk, made from fresh 
milk. To this should be added well-cooked cereals and toast 
with butter. Plenty of water should be given also. 

Medicinal. Calomel is a sheet anchor in the treatment of 
acute nephritis; it is an admirable diuretic, as well as acting 
upon the upper bowel. It should be repeated at intervals of 
several days. The initial dose should not be less than 2 grains. 
Later salines, citrate of magnesia, rhubarb and soda, cascara 
sagrada, can be tried. IsTitroglycerine in high temperature, vom- 
iting and high-tension pulse. Chloral for the nervous 
symptoms. 

Digitalis is of great service, relieving the heart and assisting 
the kidney also. Fat-free digitalis yields best results ; strychnia, 
caffeine and nitroglycerine can be used to advantage for the 
heart. 

Water^ by enteroclysis or hypodermoclysis, is of great as- 
sistance. 

If edema is great, diaphoretic measures can be used to advan- 
tage. Hot wet-packs and the hot-air apparatus bring on a whole- 
some sweat, with relief of symptoms promptly. Pilocarpine 
should be used with great caution. 

Dry cups over the loin may aid in relieving renal congestion. 
Blood-letting has been advocated, and in one of my cases was 
used with decided benefit. From 2 to 5 ounces can be removed 
without deleterious symptoms. 



DISEASES OF THE GENITO-URINARY SYSTEM 479 

In convalescence iron is early indicated in order to combat 
the anemia, Avhich is usually present. 

The urine must be constantly watched and the first evidence 
of increasing trouble instead of an improvement calls for 
prompt attention. 

CHEONIC I^EPHKITIS. 

Types. Chronic parenchymatous nephritis. Chronic inter- 
stitial nephritis. 

CHRONIC PARENCHYMATOUS NEPHRITIS. 

Etiology. Comparatively rare at any age of childhood, more 
common late. It occurs more often as sequel of the acute type 
of nephritis than as a primary condition. Prolonged sepsis, 
alcoholism, congenital syphilis, malaria, chronic gastrointes- 
tinal inflammations, etc. 

Pathology. This is essentially the same as in adults. There 
is an enlargement due to new connective tissue, the kidneys are 
white and nodular in appearance. 

Symptoms. Uusually this form originated from the acute 
variety there simply being an amelioration of the acute symp- 
toms, or perhaps a disappearance of them entirely for a short 
while, and their reappearance in this form. 

The symptoms are insidious, until the dropsy is a feature, no 
special attention being given the kidneys. There is headache 
and neuralgia, lassitude, loss of appetite, vomiting, anemia. 
The dropsy varies in amount but usually is quite marked, espe- 
cially of face and extremities. 

The urine is usually diminished in quantity, though it may 
be normal or increased. Specific gravity is low, and albumin 
present in considerable amount. The total urea output is 
greatly reduced. All the renal derivatives may be present, but 
granular epithelia are more numerous. The duration is very 
variable. It may last for years. It is essentially a chronic 
disease. 



480 THE DISEASES OF CHILDREN 

Diagnosis. This may be very difficult. It will certainly be 
made much oftener when the profession as a whole realizes the 
importance of frequent examination of the urine in all cases 
of illness. Any progressive anemia with digestive disturbance 
and loss of weight should make one very suspicious of the kid- 
neys, and call for an examination of the urine. 

Prognosis. The outlook is decidedly bad. The course of the 
disease is chronic with occasional acute exacerbations. It is 
usually one of these acute attacks which carries the child off. 
Some cases apparently recover after months of invalidism. 

Treatment. General Management. Protection from exposure 
is most essential. Warm, part-wool underclothing should be 
worn. Careful regulation of the diet, milk, carbohydrates, 
cooked fruits, buttermilk and cereals can be used. Red meats, 
eggs, fish, animal broths, should be avoided. The bowels should 
be carefully watched. Occasional purgation is indicated with 
irrigation of the colon and warm baths; water should be given 
freely. 

Eenal decapsulation, according to the operation suggested by 
the late Dr. G. M. Edebohls, has been advocated, several suc- 
cessful cases being on record. It is an operation which should 
be done with great caution. 

CHRONIC INTERSTITIAL N^EPHRITIS. 

This is an extremely rare condition in older children and 
practically unknown in infants. 

Etiology. Syphilis, malaria, tuberculosis, have been named 
as causes. 

Pathology. These kidneys are smaller than normal. The 
capsule is adherent and there is a proliferation of connective 
tissue. The connective tissue presses upon the tubules and a 
condition of hydronephrosis is caused. 

Symptoms. This form is more insidious than the others. The 
child loses in weight continuously and is anemic. Gastrointes- 
tinal symptoms are prominent, vomiting is frequent; headache 



DISEASES OF THE GENITO-URINARY SYSTEM 481 

is present, and eye symptoms, as double vision, specks before 
eyes, or complete blindness, may occur. There is usually no 
rise in temperature, but there is a high-tension pulse, and the 
left heart shows dilatation. 

The urine is increased in quantity and specific gravity is 
low. Albumin is present in small quantities or absent entirely. 
The principal casts present are the hyaline, though the other 
varieties, in the presence of an acute exacerbation may be found. 

Prognosis. This is always bad. The tendency is to a fatal 
termination, though it may show an improvement occasionally. 

Treatment. IsTot a great deal can be accomplished save the 
care of the child, protection from exposure and carefully regu- 
lated diet, and functions of the body. Change of climate is 
often of great benefit. 

TUMORS OF THE KIDNEY. 

Varieties. Benign tumors of the kidney are very seldom seen. 
The vast majority of this form of growth are malignant, and 
the commonest variety is a sarcoma. A variety of growth has 
been described by one author as embryonal adenosarcoma. 

Etiology. These growths are essentially peculiar to children, 
occurring usually between six months and four and a half or 
five years of age. It is rare to see one in children over five 
years of age. It does not occur oftener in one sex than another. 
The left kidney seems to be more often affected. The direct 
cause not known. 

Symptoms. The condition may not be recognized until the 
growth is visible to the eye. Preceding this time the cachexia 
is quite marked, there is apt to be pain and occasionally bloody 
urine. 

In the presence of the latter conditions a careful palpation 
should be made of the abdomen, and the tumor will probably 
be found. At first its growth is slow, but when easily palpable 
the growth enlarges with greater rapidity, and may apparently 
fill the whole abdominal cavity in a short while. The feel of 



482 THE DISEASES OF CHILDREN 

the tumor is usually soft, not tiuctuating, but a distinct give 
to them. 

Bloody urine is a very common symptom. It may be demon- 
strable only by the microscope, but is present in practically all 
cases. 

Albumin is present, principally because of the blood. Hyal- 
ine casts are sometimes found. 

The first symptom to call attention to the child may be a 
distinct cachexia, a something in the countenance and the skin 
which usually suggests malignancy, a different color from the 
anemia of tuberculosis. The child loses flesh rapidly and the 
prominent abdomen soon becomes a marked symptom. 

Pain more or less severe is present in practically all cases. 
It may be simply a dull but persistent ache or a severe darting 
pain, enough to make the child cry out. 

Diagnosis. A diagnostic sign usually present is the localiza- 
tion of the colon, shown by a tympanitic note over the surround- 
ing dull area. The left kidney is the most frequently enlarged. 

Kidney tumors are the most frequent of abdominal tumors 
in children. 

Prognosis. The course of malignant tumors of the kidney is 
always fatal if not operated upon. Early operation yields 
good results. Unoperated cases die within six months to two 
years. The earlier the diagnosis and operation the greater the 
chance of recovery. 

Treatment. This is essentially surgical as no other treatment 
offers any results. Pain usually requires anodynes ; paregoric, 
heroin, codeine or morphia may be given. 

Removal of the kidney and ureter for some distance offers 
the only hope of recovery, and the earlier this is done the better 
the outcome. 

hydrojs-epheosis. 

Definition. This is either congenital or acquired, and is either 
a cystic degeneration of the kidney or an accumulation of urine 
in the pelvis of the kidney from an obstruction of the ureter. 



DISEASES OF THE GENITO-URINARY SYSTEM 483 

Etiology. The obstruction of the ureter may be caused by 
the lodgement of a stone from the kidney or contraction of the 
vesical orifice of the ureter. 

Pathology. A tubule of the kidney may become blocked and 
dilated, forming the beginning of a cyst. If obstruction of the 
ureter is present the pelvis of the kidney becomes dilated and 
the cortical portion of the kidney pressed upon until it is a 
thin shell. The kidney is larger than normal, but not as large 
as a malignant grov^th. A double hydronephrosis may be 
present. 

Symptoms. These are very vague, and usually no diagnosis 
is made until the tumor is felt. It occurs later than the malig- 
nant growths as a rule. The presence of the urinary findings 
of nephritis may obscure the true diagnosis. 

Prognosis. Without surgical intervention the prognosis is 
grave, and in the double variety the end comes quickly. 

Treatment. This is entirely surgical, a nephrectomy being 
indicated in all cases. Drugs have no place in the treatment. 

EJ^UEESIS. 

Synonyms. Bed-wetting ; incontinence of urine. 

Definition. This is a continuance of the infantile habit of 
vesical incontinence into the third year. 

Etiology. The control of the bladder is a complex phe- 
nomenon. With distension of the bladder the impulse for 
evacuation passes from the nerves in the bladder Tvall to the 
brain and cord, and the impulse to the muscles of the bladder 
is carried back through the nerves, which causes its relaxation, 
and the contraction of the muscles of the bladder follows. 

Enuresis occurs in various organic diseases of the central 
nervous system; from irritation of the nervous centers, in the 
cord or brain, and of the nerves in the bladder; inflammatory 
change in the bladder; mucous membrane; abnormal urine, 
especially a hyperacidity, too free taking of fluids at bed time ; 
vesical calculus ; phimosis ; urethritis ; vulvovaginitis and ureth- 



484 THE DISEASES OF CHILDREN 

ritis; extreme nervous conditions, especially chorea; anemia; 
constipation. 

The oldest child I have seen with enuresis was a boy of 13. 

Enuresis may be nocturnal or occur only during the day, 
or both. 

Symptoms. The chief symptom is the involuntary passage 
of urine, which may occur once or several times during the 
night. If, it occurs only during the day the child may be able 
to retain the urine only an hour or so. Frequently an acci- 
dental passage of urine occurs while the child is intent upon 
its play, and this should not be classed as an enuresis. 

The habit may continue until puberty, if nothing for its 
remedy is tried. 

Prognosis. The earlier the treatment is begun, the better the 
results ; the correction of malformations yields prompt results. 
If there is an organic brain lesion the prognosis is not good. 

Treatment. Examine carefully into any cause, mechanical 
or otherwise, which is removable, and first correct this. Usually 
no other treatment is needed. Reflection of the prepuce or cir- 
cumcision in severe phimosis relieves one source of irritation, 
and while of itself does not cure many cases, is a great help. 
Build up the child; correct dietary indiscretions; limit the 
amount of water drank after 6 o'clock in the evening; awaken 
the child at 10 o'clock to empty the bladder; assist it to sleep 
upon the side and not upon the back by wearing a knotted 
towel about the waist with the knot in the lumbar region ; raise 
the foot of the bed to cause the urine to distend the summit 
of the bladder and not make undue pressure upon its neck; 
cool bathing, followed by a rub, is beneficial also. A bland diet, 
especially at night, should be insisted on. 

Medicinally belladonna gives the best results, and it can be 
given in the form of the tincture, the initial doses of 1 drop 
for each year of age, three times a day, increased a drop a day 
until the physiological effect is obtained. The dose is then 



DISEASES OF THE GENITO-URINARY SYSTEM 485 

decreased 10 per cent and kept at this for a week or so, then 
decreased 1 drop a day until it is discontinued. 

Urotropin, salol or citrate of potassium may be of benefit. 
Ergot in small doses is of value in cases due to weak bladder 
muscle. 

Atropia can be given as follows : 

I^ Atropise sulphatis gr. ss 

Aquae destillat § i 

M. et ft. solutio. 
Sig. One drop for each year of the child's age at 4, 5 and 6 o'clock in the 
evening. Strychnia can be added to the above prescription in proper dose. 

PHIMOSIS. 

A congenital phimosis, or contracted prepuce, exists in all 
male children, but with the growth of the glans penis, the adhe- 
sions are loosened and the accumulation of smegma behind the 
corona glandis separates them at this point. 

If from birth to the fourth week the prepuce is pushed back 
a little farther, daily, by the end of that time it can be easily 
pushed back over the corona glandis and the smegma removed. 
This preliminary and complete stretching and reflection dilates 
the prepuce sufficiently to make the complete uncovering of the 
glans easy, and obviates the necessity for circumcision. This 
reflection should be repeated once a week, some vaseline placed 
behind the corona and on the glans and the foreskin replaced. 
The necessity for replacement of the foreskin promptly should 
always be borne in mind as a paraphimosis is easily produced. 

Symptoms. There may be no symptoms except pain on void- 
ing urine or straining at that time without pain. The straining 
may be so great as to cause a prolapse of the rectum. Reflex 
symptoms are not uncommon when adhesions are present. I 
have seen one boy presenting symptoms of hip-joint disease 
which were completely relieved after the preputial adhesions 
were broken up. ^ight terrors may be caused by phimosis as 
well as choreic symptoms. Enuresis has been attributed to 



486 THE DISEASES OF CHILDREN 

phimosis, but other observers report little relief from this con- 
dition by circumcision or correction of the trouble by reflection 
of the prepuce. 

Treatment. 'None of these symptoms will present if early 
retraction is done, but if there is a pin-point preputial orifice 
which is very tight a circumcision should be done, with the 
entire removal of the prepuce. A dorsal incision of the prepuce 
should never be performed in lieu of a circumcision. 

PARAPHIMOSIS. 

This usually occurs in infants as the result of a reflection 
of the prepuce, the foreskin being allowed to remain behind the 
corona glandis too long. As a result a strangulation occurs, 
and a swelling of the folds of the prepuce quickly takes place. 
The swelling may be very great, the skin and mucous membrane 
become reddened, and later may become black if the condition 
is not relieved. Considerable pain is present and there may be 
difficulty in urination. 

Treatment. Manipulation may succeed in reducing the 
deformity. The penis is encircled just back of the corona 
glandis by the flngers of one hand and the other holds the 
glans, firm pressure being made simultaneously for several 
minutes. The position of the hands is then changed and press- 
ure is made upon the glans and corona glandis by the thumbs 
and index fingers, an attempt being made at the same time by 
the other fingers to draw the foreskin forward. 

Tf these manipulations fail, while the penis is flaccid and 
much of the blood has been forced out by the manipulations, 
the constricting bands are divided on the dorsum of the penis 
in the median line, the reduction then being easily accomplished. 

BALANITIS. 

This is an inflammation of the mucous membrane covering 
the prepuce and glans penis. 



DISEASES OF THE GENITO-URINARY SYSTEM 487 

Etiology. iN'egiect of the foreskin, uncleanliness, infection, 
masturbation, urethritis with confining of the secretions, and 
decomposition of the smegma. 

Symptoms. The first symptom noted will be an enlargement 
of the penis, principally near the end of the foreskin. If there 
is a phimosis the end of the prepuce seems smaller than usual. 
A discharge may be noticed, in the absence of a urethritis, 
coming entirely from the mucous membrane of the prepuce and 
gland. It may be due to a decomposition of the smegma, or an 
infection after reflection. I have seen one case in which a 
small abscess formed behind the corona from this cause, adhe- 
sions having formed around the pus and limiting it to a small 
area. Reflection of the prepuce, breaking up of the adhesions 
and cleanliness caused a prompt cure. 

Treatment. Perfect cleanliness is indicated. Boracic acid 
solution is effectual. Circumcision should be performed where 
there is enough constriction to prevent free exposure of the 
glans for cleansing. 

TJRETHEITIS. 

This is an infection of the urethra, and may be simple^ due 
to the ordinary pus-producing organisms, or specific, due to an 
infection with the gonococcus. It may effect both male and 
female babies, but is more common in older children. 

The simple form is rarely severe. There is an invasion of 
the urethra from a balanitis, or a simple "^ailvovaginitis. In the 
male the infection is usually limited to the anterior urethra 
or the fossa navicularis. Combined with a balanitis the condi- 
tion is much more serious. There is pain on urination, the 
child shrinking from a voluntary passage of urine. The dis- 
charge is not very profuse or the duration of the inflammation 
very long. 

Treatment. Urotropin by the mouth for the purpose of ren- 
dering the urine bland and unirritating, plenty of water drank. 
Is about all that is needed. 'No local treatment is indicated as 
a rule. 



488 THE DISEASES OF CHILDREN 

Gonorrheal Urethritis. Unfortunately this form of infection 
is met oftener than is the general belief. It not only occurs 
among the poor, who live in unclean and unhygienic surround- 
ings, but in the children of the well-to-do, who may employ a 
nurse who has the infection and is guilty of abnormal practices 
with the child. It occurs in boys most often between six and 
ten years of age. 

Diagnosis. The only safe diagnosis is by examining the 
stained urethral discharge under the microscope. All urethral 
discharges should be examined in this way for diagnosis. 

Symptoms. A profuse, thick, creamy discharge from the 
urethra is present. There is pain on urinating, which may only 
be at the passage of the first few drops, or accompanied by 
severe tenesmus upon the completion of urination. The penis 
is usually swollen and tender. 

The chief complication to be feared is conjunctivitis because 
of the carelessness of the child. Orchitis, epididymitis and 
arthritis are uncommon in children. 

Treatment. This does not differ in any essential from a 
specific urethritis in an adult, except that urethral irrigation 
is impracticable. Water, taken freely ; urotropin, gr. iii to v, in 
boy of six ; santal, 5 min., will be found of service. A balanitis, 
complicating, also demands attention. 

VULVOVAGINITIS. 

This is an inflammation of the mucous membrane of the 
vulva, with secondary involvement of the urethra, vagina and 
possibly the cervix. It is simple or specific^ the latter most 
often due to gonorrhea. 

Etiology. The simple form is usually due to uncleanliness ; 
using the same napkin several times after it is wet before it is 
washed; pin-worms, or other infection from the rectum as the 
colon bacillus ; the exanthemata ; in institutions where the same 
towel is used by a number of children ; trauma and mas- 
turbation. 



, DISEASES OF THE GENITO-URINARY SYSTEM 489 

The specific form is due to an infection from the gonococcus, 
and in every case of vulval inflammation the discharge should 
be carefully stained and examined microscopically. It is 
usually conveyed by a towel or washcloth, infected by an adult, 
similarly affected. A mother may innocently have a latent 
gonorrhea, cervical or vaginal, and infect the child direct 
through the medium of the hands. I have had two cases 
recently. In one the father had an acute attack at the time and 
infected a towel, in the other the closest questioning has failed 
to reveal the source of contagion, though a colored nurse is 
strongly suspected. 

Symptoms. The simple form may present few if any symp- 
toms, except a discharge. This may amount to very little, save 
a slight staining of its clothes. The vulva may be slightly 
congested, but usually this is not at all severe. 

Glandular enlargement in the groin may be noticed, with 
or without pain. 

In the gonorrheal form the process is rarely limited to the 
vulva, the invasion of the vagina and cervix being usual, as 
well as of the urethra, evidenced by tenesmus, frequent passage 
of urine or a desire to do so. There is a burning and itching. 
The discharge is quite thick and creamy, there is apt to be a 
sticking together of the labia, and an accumulation of pus in 
the ostium vagina. After a time there is no pain or discomfort., 
the only thing being the disagreeable discharge of pus. There 
usually is an enlargement, sometimes painful, of the inguinal 
glands, which may keep the child from walking or crawling. 

The specific form lasts longer than the simple, usually from 
four to six weeks. The last case I had under my observation 
was in the two-year-old child of a patient, a most intelligent 
and faithful mother, with a persistence of the discharge for 
nearly seven weeks. The examination of some of the secretion 
about the vulva is the only way that the progress of the case 
can be reckoned. 



490 THE DISEASES OP CHILDREN 

Complications. Atresia of the vagina may occur; conjunc- 
tivitis, orchitis, epididymitis, inflammation of the glands of 
Bartholin, arthritis, inguinal adenitis. 

Prognosis. This is good, but the duration is usually longer 
than in the simple form, averaging four weeks and often much 
longer. Diagnosis can only be made by a microscopic examina- 
tion of the pus and should be done early. 

Treatment. The vulva and vagina should be carefully irri- 
gated with a 1/5000 bichloride of mercury solution, followed 
by a solution of nitrate of silver, 2 per cent. In 1/200 solution, 
argyrol can be used instead of the nitrate of silver. Extra pre- 
cautions should be taken to limit the possibility of contagion 
of the eye, as an inflammation there is apt to take place unless 
most careful precautions are taken. 

The inoculation treatment of specific vulvovaginitis has been 
used with some success.* 

The patient's opsonic index is taken every other day accord- 
ing to Wright's method. At first the index should be compared 
with that of several healthy boys. 

The tolerance for the serum by the different patients varies, 
but an average of 1,000,000 is given and increased according 
to the index gonococcus. Local reaction usually takes place at 
the site of injection, as an indurated tender area. A general 
reaction is rarely seen. The injections are given every fifth 
or sixth day. The conclusions reached from observation of a 
large number of cases is that the vaccine treatment shortens 
the duration of an attack, that old strains are more effective 
than fresh ones, the serum treatment is not to be recommended. 

The diet should be unirritating and nourishing; water taken 
freely between feedings. 

Because of the possibility of involvement of the scrotum and 
contents in male infants, the child should be kept in bed entirely 
during the acute stage. 

* Churcliill-Soper: Journal American Medical Association, vol. li, no. 16, 



DISEASES OF THE GENITO-URINARY SYSTEM 491 

Treatment should be continued as long as there is any dis- 
charge, and discontinued only when no cocci are found on 
microscopic examination of the vulval secretion. 

CYSTITIS. 

This is an inflammation of the mucous membrane of the 
bladder, it rarely occurs as a primary condition but most fre- 
quently as a result of a calculus in the bladder, or secondary 
to a balanitis or a urethritis, the latter usually of specific origin. 
It may be due to an invasion direct of the colon bacillus. 

Symptoms. There is a distinct history of frequent and nearly 
always of painful micturition, which has lasted a variable length 
of time. Mild cases may not complain ,of pain. There may be 
pain in the perineum of the male and discomfort or pain in the 
lower portion of the abdomen. 

The urine is cloudy and contains epithelium and pus, prob- 
ably a trace of albumin. Frequently there is blood present also. 

Prognosis. Prompt recovery is the rule, except when the 
infecting organism is the gonococcus. 

Treatment. Usually rest in bed, milk diet, copious drafts 
of water and urotropin, in from 3 to 5 grain doses, is all that 
is needed. In very acute cases, with painful urination, an 
anodyne may be needed. Bladder irrigation is not always nec- 
essary; when indicated a boracic acid solution, 1 or 2 ounces 
at a time, can be introduced and immediately withdrawn. 

UI^DESCEI^DED TESTICLE. 

During the early months of intrauterine life the testicles rest 
in the abdominal cavity, postperitoneally, just below the kid- 
neys. They pass downward and enter the scrotum, through 
the inguinal canal about the ninth month of intrauterine life. 

The testicle, one or both, fails to descend into the scrotum in 
the proportion of about 1 in 500 cases. It may be interrupted 
in its descent in the cavity ; at the internal ring ; or it may 
lodge in the inguinal canal. 



492 THE DISEASES OF CHILDREN 

Cases in which the lodgment is in the cavity demand no inter- 
ference, but those which lodge at the internal ring or in the 
canal the indication for interference is present, as the organ 
may become injured; inflammatory conditions of the cord and 
testicle are more apt to occur, and hernias prone to develop. 

For the relief of this condition Bevan"^ has suggested opera- 
tive procedures as follows: An incision 3 inches long over the 
inguinal canal dividing skin, fascia and external oblique 
aponeurosis. A pouch of peritoneum is found under the exter- 
nal oblique extending from the abdominal peritoneum through 
the canal to the scrotum, even in cases in which the testicle 
has remained in the cavity. The pouch of peritoneum is opened, 
cutting through the thin layers of cremasteric muscle and fascia 
and transversalis fascia. Transverse division of the vaginal 
process is made above the testicle and the upper end closed Avith 
catgut. The lower end with a purse-string suture, thus making 
a tunica vaginalis for the testicle. The peritoneum is wiped 
from the cord with a sponge, and the fibrous strands in the 
cord torn with fingers or forceps, the cord being freed of every- 
thing but the vas and vessels. If the testicle will not reach 
to the bottom of the scrotum, it may be necessary to ligate and 
cut the spermatic artery and veins. Blunt dissection of the 
peritoneal pouch with the finger may be necessary to allow the 
testicle to be pushed in, where it is retained by a purse-string 
suture within the neck of the scrotum. The wound is then 
closed as in any hernia operation. 

The age for performance of this operation is between 5 and 
12 years of age. 

* Keen's Surgery, vol. iv. 



CHAPTER XXI. 

^UTEITIONAL DISORDERS. 
ATHEEPSIA. 

Synonyms. Malnutrition; marasmus; inanition; wasting 
disease. 

Etiology. This condition develops most frequently as a 
sequel to the acute gastrointestinal disorders, in which the 
digestive disturbance becomes chronic. 

It is characterized by atrophy of the tissues and a progressive 
loss in weight and strength. Heredity' plays an important role 
in the etiology. Weak and delicate parents have poorly resisting 
oifspring. 

Environment is a decided causative factor. Children in over- 
crowded tenement districts, with badly ventilated sleeping quar- 
ters, who get but little fresh air and have poorly prepared food, 
are liable to develop this condition. 

The most important cause is the food. The food itself may 
be all right but its mode of preparation, method of administra- 
tion and quantity may result in an intestinal intoxication with 
resultant malnutrition. 

It usually begins after the sixth month of life, and reaches 
its height before the second year, if the child survives this long. 
It is rarely seen among children who are breast fed. 

"Hospitalism" is sometimes a cause. For some unknown 
reason a child may not do well in an orphan asylum, and if its 
surroundings and environment are changed without change of 
diet they do well. 

Pathology. There is no distinct pathology to this condition ; 
coincident with the general atrophy and wasting of the tissues 
there is an atrophy of the glandular structure of the digestive 
tract. There is a condition of lymphatism, an enlargement of 

493 



494 THE DISEASES OF CHILDREN 

all the lymph nodes of the body, especially of the mesentery, soli- 
tary glands of the intestines and the bronchial glands. 

The subcutaneous fat is absorbed and the skin of the body 
is wrinkled and lies in folds. As the condition progresses, the 
skin of the face becomes tightly drawn over the bones and the 
child assumes the old-man appearance w^hich is so characteristic. 

Symptoms. In every case of acute gastrointestinal disorder 
the possibility of its terminating in a condition of athrepsia 
should be borne in mind, and the child put on a gaining diet at 
the first possible moment, without overtaxing the digestive capac- 
ity. The scales are the best guide as to the importance of this. 
A progressive loss in weight each week is an indication for 
increased watchfulness. 

Athrepsia is essentially an insidious condition, reaching an 
alarming proportion in a period extending over several months. 

There is a progressive loss in weight; the subcutaneous fat 
disappears and the skin lies in folds ; it is harsh and dry to 
the touch; the abdomen soon becomes distended from accumu- 
lation of gas in the stomach and intestines, principally in the 
colon. It is restless and irritable, crying constantly; the tem- 
perature is apt to be subnormal, with occasional rises, from 
an intercurrent intestinal toxemia or indigestion. 

The bowels are apt to be constipated ; but thin mucus move- 
ments are occasionally seen. 

It is rare that two actions passed are of the same color or 
consistence. They are more often green than of the normal 
color, and frequently contain undigested particles of food, and 
are universally of a foul, putrefactive odor. 

Because of the irritating character of the discharges the skin 
of the buttocks develops an intertrigo ; it is red, thickened, and 
may become moist if it breaks down. 

Dentition is delayed and a stomatitis is apt to occur; the 
tongue is usually dry, cracks develop at the corners of the mouth. 

The child will usually act as if famished, and will take 
eagerly any food or water which is given. Vomiting is f re- 



NUTRITIONAL DISORDERS. 495 

quently present, chiefly owing to the rapidity with which food 
is taken and the over-distending of the stomach. Dilatation 
of this organ quite regularly results. 

The condition is progressive and a fatal result almost 
inevitable. 

Diagnosis. The differentiation of athrepsia from the less 
serious forms of malnutrition is difficult, as there is no fine-cut 
line of difference. It must be differentiated from tuberculosis 
and congenital syphilis. In the former there is apt to be a 
rise in temperature, probably with signs in the chest if of that 
form. The localization of tuberculosis in any organ or struc- 
ture should make the diagnosis easier. The enlargement of the 
lymph nodes in both forms makes this occurrence of no assist- 
ance as a diagnostic sign. 

In congenital syphilis the changes in the skin and mucous 
membranes, snuffles, history and, as a rule, earlier development 
of symptoms assist in the differentiation. 

Prognosis. The condition is invariably a grave one, espe- 
cially in the severer forms of the .trouble. Where hospitalism 
is a feature the results are universally bad. 

Treatment. A most careful inquiry must be made into the 
routine of the child's life, its feeding from birth, with details 
of the various changes in the diet, and a record made of the 
character, of preparation and quantity of the food given. This 
is most essential as the diet is so often at fault primarily. 

If its environment and surroundings are at fault these must 
be changed. If hospitalism is present, endeavor to have the 
child placed in a private family or isolated in larger quarters 
with more air available. A change of climate is often of great 
benefit in children in private homes. 

Regular bathing, bran baths, salt rubs, olive-oil rubs, after 
the water baths ; careful attention to the skin of the buttocks, 
and to the napkins and feeding apparatus ; plenty of out-of-door 
air; attention to the mouth, with frequent use of a boracic 
acid mouth wash. The most important consideration is of the 



THE DISEASES OF CHILDREN 

food, which must be regulated as soon as the gastrointestinal 
tract has been placed in as normal a condition as possible. This 
is brought about by giving an initial dose of calomel, gr. i in 
^ gr. doses, repeated at half-hour intervals, and followed by a 
dose of oil. 

If on the breast the milk must be examined and the deficien- 
cies in it corrected by artificial feeding, or a suitable wet-nurse, 
if possible. A preliminary examination of the milk of the w^et- 
nurse must be made. 

If on a modified milk, this should be withdrawn until after 
the preliminary cleaning out of the intestinal tract, a dextrin- 
ized barley water being temporarily given. 

A modified milk, low in fat percentage, should be given at 
first, and in small quantities at two-hour intervals. As the 
child evidences an ability to take care of the food it can be 
increased both in strength and quantity. 

The importance of obtaining a certified milk, or milk of equal 
cleanliness, should be emphasized. Whey is a valuable food 
to be used during the period of getting the child on to a gain- 
ing diet. 

A prescription as follows can be used to advantage at first: 
Fat 0.5 to 1.0, sugar 6.0, and proteid 0.5 to 1.0, the proteid 
increased slightly more rapidly than the fat as the child shows 
evidence of ability to care for it. 

The tendency is to give these babies cod liver oil or olive 
oil, to bring up the fat deposit in the system, but it should be 
given with great caution. Fats are poorly taken care of in 
the intestine, and the intestine can be easily overwhelmed. With 
these, if given in addition to the regular diet, lavage can be 
used in the obstinate vomiting cases, and gavage in those cases 
in which vomiting continues in spite of stomach washing. 

The advantage of using partially or completely peptonized 
milk in the beginning of these cases should be borne in mind, 
but should not be too long continued. 

Tonics have their place in the treatment of this condition ; 



NUTRITIONAL DISORDERS 497 

as minute doses of stryclinia, iron, diastatic agents, as pan- 
creatin, etc., and stimulants, in certain cases may be indicated. 

SCORBUTUS OR SCURVY. 

This is a constitutional nutritional disease due to prolonged 
error in diet.- Hemorrhages are its chief manifestation, and 
these may be in the joints, under the periosteum of the bones, 
or from the mucous and serous membranes, and in the tissues. 

Etiology. This is particularly a disease of infancy, being 
seen most often before the second year of age, rarely before the 
fourth month. The diet is the chief cause, viz., prolonged use 
of one of the artificial foods, condensed milk, cow's milk in 
improper modifications, which usually has been Pasteurized or 
sterilized. Isolated cases have been reported as developing in 
children who have been on breast milk exclusively. These have 
been rare, however. The continued use of any food which 
lacks the vital quality of freshness, will cause scurvy. 

Pathology. The chief changes are in the blood vessels which 
permit of the escape of blood into the joints or tissues, or a 
changed blood which can escape from more or less normal blood 
vessels. The chief hemorrhages seen are under the periosteum 
of the long bones, principally of the lower extremities, in the 
joints, from the mucous membranes, and in the subcutaneous 
tissues. The bones of the arms are less often affected, but 
hemorrhages do occur at the ends of the ribs and on the scapula. 

ISTumerous ecchymotic spots appear in the skin of the body. 
The mucous membrane around the teeth and of the gums, 
becomes spongy and bleeds if touched. The teeth may become 
loosened. 

Symptoms. The child usually gives a history of doing badly 
for several weeks, is pale and anemic and more restless than 
usual. Suddenly, if it has been walking, it refuses to stand, 
and cries when handled. The joints become swollen and very 
tender, and there may be pain when the child is entirely quiet, 



498 THE DISEASES OF CHILDEBN 

but this is not usually the case. Examination of the legs reveals 
swellings along the shaft of the long bones and near the epiph- 
yses, and the joints are swollen, usually without redness. 

The skin may show a number of hemorrhagic spots, like 
bruises, some large, or there may be a number of petechial 
spots scattered over the body. Characteristic changes occur in 
the mouth. The gums are spongy and usually extend some dis- 
tance up on the teeth, and they bleed on the slightest touch. 
The gums may not break down, if no teeth are present, but the 
mucous membrane over them usually shows a number of small 
hemorrhagic areas. 

Melena may be present and blood in the urine is not uncom- 
mon, with blood casts and albumin present also. A single or 
double exophthalmos due to blood in the orbit may be present, 
but this is not at all a constant symptom. A subconjunctival 
hemorrhage sometimes occurs. Discoloration of the skin around 
the eye, a so-called ''black eye," is often present, especially 
when there is an exophthalmos. Hematuria is not infrequently 
present. In regard to the blood count in scurvy. Da Gosta 
reports, as a result of examination of seven cases, an average 
hemoglobin percentage of 43 per cent, an average of red cells 
of 3,527,000, the average leucocytes of 15,500. In only one 
of the seven cases was there a leucocytosis. 

Diagnosis. The chief trouble to be diagnosed from is rheu- 
matism. I have seen three cases, in each of which the child 
had been vigorously treated for rheumatism, and each pre- 
sented the classical symptoms of scurvy. If the chief patholog- 
ical conditions of scurvy are borne in mind the diagnosis is 
plain, as a rule, viz., hemorrhages under the periosteum and in 
the joints, and the typical changes in the gums. Owing to the 
forced immobility from the pain in the joints the legs have the 
appearance of being partially or completely paralyzed. The 
muscles are tense, to protect the leg, and have none of the true 
appearance of a paralysis. Occasionally there is a rise of tem- 
perature, but it is irregular and rarely high. Among the other 



NUTEITIONAL DISORDERS 499 

conditions which may be mistaken for scurvy are as follows : 
Periosteitis, osteomyelitis^ hip disease^ injury, difficult dentition. 

Prognosis. This is universally good if the condition is recog- 
nized early and appropriate treatment begun. Even the hemor- 
rhages causing the exophthalmos are quickly absorbed. Delay 
in the diagnosis prolongs convalescence proportionately long. 

Treatment. This is essentially one of diet, no medication 
being required. Inquiry should be made in detail in regard 
to the feeding, and it should be taken off all proprietary foods, 
and put on fresh, unsterilized cow's milk at once. If the child 
is under one year, the milk should be so modified that the fat 
and proteid contents are not too high; if over one year of age 
a 4 per cent milk can usually be easily taken care of. 

In addition to the milk the child should be given strained 
orange juice, which is practically a specific, at first half an 
ounce twice daily, between feedings, gradually increased to 
1-| or 2 oimces. One or two feedings a day of an animal broth, 
or the expressed juice from beef, will be found most beneficial, 
and one feeding of a small, baked Irish potato daily. One 
or two tablespoonfuls of the beef juice can be given alone or 
as gravy over the potato. 

Careful regulation of the hygienic conditions should be made, 
the child kept in a bright, airy room, with plenty of sunshine. 
It should be kept quiet and not handled more than necessary 
to keep it clean, and the improvement will be decided in the 
course of three or four days. 

Medication is, as a rule, not needed, except it be to combat 
the anemia which is present in nearly all cases, especially if of 
long standing. 

Iron in some form will be well borne: 

I^ Tinct. ferri chloridi 3ii 

Glycerini §ss 

Aquae destillatse q.s. 5ii 

M. ft. Sol. 
Sig. One teaspoonful after eating, three times a day. 



500 THE DISEASES OF CHILDREN 

The prevention of scurvy is of great importance. The diet 
of every artificially-fed infant should receive careful super- 
vision, proprietary foods not used, and the progress report reg- 
ularly sent in for the guidance of the physician. 

RACHITIS. RICKETS. 

This is a constitutional disease in which the most striking 
changes are in the bones, the principal site being the epiphyses, 
though more or less marked changes occur in every other organ 
and tissue of the body. 

Etiology. Bad hygienic surroimdings and unsuitable food 
are the principal causes. Infants who are breast fed well into 
their second year, or who are getting a breast milk below 
standard in quantity and quality, or the artificially fed in whom 
the proprietary foods or condensed milk are given to practically 
the exclusion of fresh food, are prone to develop rickets. From 
this we would scarcely expect to see a case before the sixth 
month, but cases of fetal rickets have been reported. In con- 
densed milk, and in some of the proprietary foods also, the chief 
element lacking is the fat, as in any dilution recommended 
the fat content is low. 

A history may be obtained of a previous exhausting disease, 
as a prolonged gastrointestinal disturbance or the exanthemata, 
a bronchitis of some weeks duration, or other exhausting dis- 
ease, always, however, in connection with some irregularity in 
diet or a failure to give the child a well-balanced ration, which 
is meeting the needs of its nutrition. 

Rickets is more frequently found in the colored race than 
in any other, next in frequency perhaps in Italians. In both 
these races over-crowding, unhygienic surroundings and im- 
proper food are present. 

Pathology. All of the tissues of the body share in the nutri- 
tional changes found, but because of the prominence of the 
bony changes attention is chiefly focused to them. The bony 
changes occur in the centers of ossification and consist in the 



NUTRITIONAL DISORDERS 501 

excessive deposit of cartilage at these points. In the long bones 
it is at the epiphyses, in the flat bones, especiallv of the skull, 
it is in the center. Owing to the deficiency in the lime salts 
in the cartilage cells these fail to ossify, and all the bones are 
soft and more or less flexible ; OAving to this condition the fairly 
characteristic bony deformities of rachitis take place. Cranio- 
tabes is a characteristic condition, being a softened area to the 
sides of the occipital protuberance, which can be very easily 
demonstrated. 

There is a congestion or hyperplasia of the periosteum at the 
ossification centers. Microscopically a marked increase in the 
new cartilage cells is seen, and an increased vascularity of the 
proliferating zone. 

Anemia is always present, the hemoglobin is relatively low. 
Morse's^ cases averaged 63 per cent with a color index of 0.7. 
The red cells in his cases averaged over 4,500,000. 

Leucocytosis is present in many cases, but not in all by any 
means. 

The muscles are flabby, the heart weak and irritable. 

Bronchitis and pneumonia are frequent complications, there 
seeming to be an almost constant state of passive congestion of 
the mucous membranes. 

There is an enlargement of both the liver and the spleen, espe- 
cially the latter. The spleen can quite easily be palpated below 
the costal margin. 

Symptoms. Focal. The head of the rachitic child is en- 
larged, the bitemporal and bi parietal diameters are increased. 
Bosses develop at the centers of ossification, chiefly of the 
parietal and the occipital bones. The forehead is high, and the 
fontanelles are both late in closing. Frequently the sutures 
are found ununited. 

The rachitic rosary is a fairly constant symptom. This is 
an enlargement of the ribs at their costal margin and gives the 
impression of a string of beads. If these enlargements are of 

* Boston City Hospital Rep., 1897. 



502 THE DISEASES OF CHILDREN 

some size thej will make an indentation on the lungs under- 
neath. As a result of the softening of the costal cartilage the 
atmospheric pressure pushes in this portion of the chest wall, 
causing the sternum to be more prominent. This deformity is 
called a pigeon breast, and is fairly characteristic. 

The ends of the long bones show an enlargement, the epiph- 
yses at the wrist being specially large. 

If the child is walking, the weight of the superimposed body 
causes a bend in the femur and bones of the leg, as well as an 
exaggeration of the curves of the spine. A lateral curvature 
not unusually develops. Genuvalgum, a knock-knee, and genu- 
varum, bow-legs, are common deformities. An anterior curva- 
ture of the tibise is often present. This is probably, in part, 
at least, due to the child sitting in a chair with its feet extend- 
ing beyond the anterior edge, the weight of the foot causing 
the bend in the tibia. 

At this stage of bony formation, softening of the pelvic bones 
may result in female children in a flattening of the pelvis, 
causing the flat rachitic pelvis which results in the child-bearing 
period in a dystocia. 

Dentition is delayed and often difficult. After the teeth 
are cut they are soft and decay early, the front teeth often 
crumbling away. 

Systemic Symptoms. The anemia appears early and is fre- 
quently quite pronounced. 

Owing to the loss of tone of the musculature the stomach 
and intestines become distended, and the child presents a "pot 
belly." Attacks of gastroenteritis are frequent. Constipation 
is the rule. 

Head sweating is an early and prominent symptom, and when 
present should put the physician at once on his guard. The 
child's pillow will be wet whenever it lies down to take its 
nourishment or to sleep, and its hair quite wet, with beads of 
perspiration on its forehead and neck, and this in spite of the 
temperature of the room. 



NUTRITIONAL DISORDERS 503 

It is very restless and sleep is greatly disturbed; it will cry 
out in its sleep very frequently. It is often wakened at night 
with a spasmodic condition of the larynx^ causing a peculiar 
crowing-like sound. This is laryngismus stridulus and is a 
fairly constant diagnostic sign. 

The child is backward in walking, due to the deficient mus- 
cular power. The association of adenoids and rachitis is not 
infrequent, the child being a mouth breather in consequence. 

Pro^osis. Eickets is a chronic affection, usually mnning 
its course in about two years, if upon the proper diet or treat- 
ment. Because of their weakened state and lack of resistance 
rachitic children are more likely to develop the acute exan- 
themata, diphtheria, whooping-cough, pulmonary diseases, etc. 

Prognosis is worse in diseases of this nature in the rachitic. 
There may be a gradual absorption of some of the bony deposit 
at the epiphyses and bosses, but the deformities do not disappear. 
The flat rachitic pelvis, the gennvarum and valgum, the kypho- 
sis, remain during the life of the child. 

Diagnosis. In every case not doing well rickets should be 
borne in mind, as its earliest symptoms are vague and might 
go imrecognized. Eut if the principal symptoms are remem- 
bered the diagnosis should be easy, viz., head sweating, rachitic 
rosary, enlargement of the epiphyses, craniotabes, constipation, 
delayed dentition, restlessness at night, anemia, laryngismus 
stridulus, should make the diagnosis easy. 

Treatment. The principal indication is to learn the cause, 
if possible, and remedy it. If it is the feeding which is at 
fault it must be carefully regulated, fresh and properly modi- 
fied milk given ; proprietary foods must be withdrawn ; scraped 
beef is of great assistance in building these cases up. If the 
quality of the breast milk is found at fault, with ample quan- 
tity, the nursings should be shorter and the child given a small 
artificial feeding after nursing of a modified milk with foraiula 
suited to it5 needs. If on modified milk the same formula may 



504 THE DISEASES OF CHILDREN 

be kept up for too long a period and be unequal to the demands 
of nutrition when teething has begun. This is seen very often. 

If on a mixed diet, it may be found the child makes one or 
two meals on cereals, heavily loaded with sugar, drinks but 
little milk, rarely tastes meat, eats much potato and bread. The 
proteid and fat in its diet is greatly lacking, and this must be 
regulated by the use of milk, cream, scraped beef and beef 
juice, animal broths, and of butter in the older children. 

Regulation of the child's surroundings and daily routine of 
living is of vast importance. If in the crowded districts of a 
city they can't get the fresh air so necessary to their vitality. 
These children need plenty of air and out-door sunshine. Fresh 
air must be in the sleeping rooms also. The daily bath is very 
necessary, which should be followed by a cool sponge, especially 
over the chest and back, for the purpose of inuring them to the 
changes in the atmosphere. 

Medicinal. Cod liver oil, in these cases, is of great benefit, 
and it can be used either plain or in an emulsion. 

The oil should be looked upon as a food as well as medicine, 
and its effects closely watched. If it is regurgitated or if it is 
passed unchanged in the stools the dose must be lessened or 
it should be temporarily withdrawn. If used plain it can be 
given in gradually increasing doses, until the maximum dose is 
reached, from 5 drops to 1 teaspoonful, after meals. 'None of 
the so-called extractives of cod liver oil are satisfactory. 

Owing to the lime needed in bony formation, the combina- 
tions of the hypophosphites of lime with the emulsion of oil 
are of benefit. 

Considerable discussion has been indulged in by the pediat- 
rists on the value of phosphorus in rickets. In my experience 
it has been of unquestioned benefit. It can be given either 
as the officinal oil of phosphorus, with olive oil or cod liver oil, 
in dose of 1/200 to 1/100 grain, three times a day. Thomp- 
son's solution containing 1/20 grain to the drachm can be used 
also. 



NUTRITIONAL DISORDERS 505 

Iron in some form is nearly always indicated sooner or later 
to combat the tendency to anemia, and can be given in the 
form of the hypophosphite (ferri hypophosphis, U. S.), 1 to 2 
grains, in the form of a syrup ; the tincture of the chloride of 
iron, with glycerine; or diastiron in drachm doses. These 
should be given after eating. 

For excessive head sweating atropia sulphate in 1/800 grain 
doses can be given at bed time. 

Other conditions should be treated as they arise, pulmonary, 
dietetic and gastrointestinal complications. 

Deformities should be appropriately handled. Spinal curva- 
tures by decubitus ; tendency to bow-legs or knock-knee by 
keeping the child off its feet and off the floor. Deformities of 
the pelvis cannot be prevented except as they are arrested by 
the general improvement from appropriate treatment of the 
general underlying condition. 



CHAPTEE XXII. 

Diseases of the E'ervous System. 
general considerations. 

The nervous system of the new-born child differs from the 
older child and adult, in that it is more immature in develop- 
ment than any of the rest of its tissues. During the first Rve to 
seven years of its life it develops more rapidly than the rest 
of its body, especially as to its function. Early the brain is 
unstable, there is but little inhibition of nerve force or energy, 
and there is also no development of the centers controlling the 
involuntary muscles, the sphincters, especially. The nerve cen- 
ters of an infant or child react to reflex stimulation much more 
readily than when the nervous system is mature. This accounts 
for the frequency of convulsions in the infant. The nervous 
system of the child is more susceptible to depressing influences 
of impoverished blood than the adults, this being specially true 
of girls, up to the time of puberty they are more prone to 
develop serious functional and organic nervous trubles. 

The question of heredity, so little understood, is one to be 
seriously thought of in the diseases of the nervous system. 

ITervous diseases are either functional or organic. Among 
the former are chorea, convulsions of reflex origin, neurasthenia, 
hysteria, in these troubles there being no pathological condition 
responsible for the disease. In the organic form there are 
pathologic changes in the cells and nerve tissue. 

DIAGNOSTIC METHODS. 

With a nervous disorder suspected, a careful, systematic 
examination must be made. In conditions such as chorea or 
hysteria, if the child can be watched at play, or while recum- 
bent, entirely casually, without the child's attention being called 

506 



DISEASES OF THE NERVOUS SYSTEM 507 

to the fact that it is being watched, a much better idea of the 
symptoms can be had. If the child is under constraint with 
a consciousness of being watched, the symptoms will be modified. 

It may be necessary to have the child walk, if possible, to 
learn whether there are any paralyses, the character of the 
gait, whether there is a spastic condition of the muscles of the 
extremities, atrophies or deformities. The child should be 
made to squeeze one or two fingers of the examiner to obtain 
contractile power of these muscles, to hold the hand out straight 
to obtain any fibrillary twitchings of the muscles. The examina- 
tion should not be concluded without the child is stripped and 
all parts of its body examined, especially the spine. 

The reflexes must be tested, the most important being the 
following : 

The Knee-jerk. In the very young this is difficult to ob- 
tain, in older children it can be gotten. The legs are allowed 
to hang over edge of chair or table and patellar tendon struck 
gently with the end of the finger, as in percussion. The child's 
attention is diverted during this manipulation by having it 
clench its hands tightly together and pull hard. 

The Biceps Jerk. The child's arm is held flexed and relaxed 
with the thumb of the hand supporting the arm, held along the 
biceps. With the second finger or with a percussion hammer 
the biceps is struck a gentle blow direct, or the thumb is per- 
cussed and the muscle can be felt to contract. 

Cremasteric Reflex. By stroking the inner aspect of the 
thigh with the finger the muscle of the scrotum contracts, rais- 
ing the testicles. 

Sensation. The examination for sensation should include the 
examination for the presence or absence of sensation of pain and 
the period of time which elapses before the sensation is received. 
A pin, camel-hair brush, hot and cold substances, are needed 
to elicit this symptom. The child's expression should be closely 
watched for the evidence of the reception of sensory impres- 
sions. This symptom is of importance in spinal cord lesions. 



508 THE DISEASES OF CHILDREN 

The fontaiielles should be examined and note made if they are 
open, sunken or bulging and tense. 

Babinski's Reflex. Irritation of the soles of the feet causes 
a dorsi-flexion of the great toe toward the dorsum of the foot, 
while the other four toes are flexed toward the sole of the foot. 

Kernig's Sign. In 1882 Kernig described a condition which 
is more or less pathognomonic of meningitis. It consists in 
the inability to extend the leg fully on the thigh, the thigh being 
flexed at a right angle with the trunk. It is involuntary and is 
not accompanied by or due to pain. Kernig considers the sign 
positive when the angle is 135°; others place it at 120° or 
even 115°. 

Morse concludes it is almost never found in infancy, either 
in health or disease, except in meningitis. It occurs with equal 
frequency at all stages of the disease. It is of no importance 
as a diagnostic sign between the tuberculous and cerebrospinal 
forms. 

The vision of the child should be tested. The mother is 
often deceived as to this point. A lighted taper or bright ob- 
jects moved in front of the eyes will cause them to follow the 
object back and forth. The pupils are examined to ascertain 
if they are equal, and if they contract promptly to light stimu- 
lation. Constant movement of the eye, nystagmus, is a very 
striking symptom. 

Squire's Sign. The child lying on its back, the head is grasped 
and slowly extended as far as possible. The pupils dilate during 
this and contract as the head is flexed. 

Electrical Examinations. As an aid to diagnosis electricity 
is of great value. The nerves of the new-born respond only to 
strong currents. 

The examination is begun with the faradic current, one pole 
on the muscle to be examined the other on the chest, and only 
a current strong enough to produce a contraction is used. In 
inflammatory and degenerative conditions of the nerves, both the 
nerves and muscles show a diminution in the faradic response, 



DISEASES OF THE NERVOUS SYSTEM 509 

but the muscles may continue to partially respond to the gal- 
vanic current, and these changes are called the reaction of 
degeneration. 

Electricity is also of value in differentiating cerebral disease 
and diseases of the spinal cord and peripheral nerves. 

Lumbar Puncture. As a method of diagnosis this procedure 
is of value, and is performed as follows : The child can lie upon 
its side, with head and shoulders elevated, and slightly bent 
forward, putting the tissues of the back on a stretch. The latter 
position favors the flow of fluid. The skin is thoroughly ster- 
ilized with soap and water and alcohol. A general anesthetic 
can be administered if desired, or local anesthesia with cocaine, 
Schleich's solution or kelene. 

The puncture is made with an ordinary aspirating platinum 
needle or small trocar, 9 or 10 cm. long, and 1 mm. in diameter, 
which is sterilized by boiling 10 minutes. The puncture does 
not hurt much more than the introduction of the cocaine. 

The space between the third and fourth, or fourth and fifth, 
lumbar vertebrae is selected, as at this point the cord is not 
injured. The iliac crests are on a level with the fourth spinous 
process, and the needle with one motion plunged to the inter- 
v^ertebral cartilage 1 cm. to one side of the median line. If the 
cartilage is located with certainty the canal is entered with the 
point of the needle, and to a depth of about 3 or 4 cm. The 
cerebrospinal fluid at once escapes, at the rate of 1 or 2 drops 
a second, or even slower in some cases. To make a thorough 
examination of the fluid 4 cc. to 5 cc. should be obtained, and 
should be dropped directly into the capillary tube of the centri- 
fuge, after obtaining enough for cover-slip examination. 

The normal cerebrospinal fluid is clear, and of a gravity of 
1003, and contains a trace of albumin and is practically free 
from cells. In inflammation of the meninges the fluid is 
cloudy from an exudation of cells, dependent of course upon the 
character of the exudate. In the tubercular form there is very 
little cellular exudate. 



510 THE DISEASES OF CHILDREN 

Cover-glass preparations (from the fresh fluid as it is with- 
drawn or from the sediment in the capillary tube, the latter 
preferable) are stained with Wright's stain. Tothe's method 
of diagnosis has been given. 

In tubercular meningitis the fluid appears clear, as a rule, 
except on close examination. If the test tube containing the 
fluid is allowed to stand upright in an ice box for 24 hours a 
precipitate or coagulum, wedge or funnel-shaped forms, which 
is fairly characteristic of this type. 

If many polynuclear leucocytes are found in the sediment 
it is not the tubercular form. The large and small lymphocytes 
in the sediment indicate tubercular meningitis. The inocula- 
tion of guinea-pigs may be necessary to clear up the diagnosis 
of the tubercular form. 

In the suppurative form of meningitis the fluid is very 
cloudy and contains pus cells, and a large number of leucocytes. 

In epidemic cerebrospinal meningitis the same procedures 
are gone through with and the sediment examined for the diplo- 
coccus intracellularis. 

FUNCTIONAL DISEASES OF THE NERVOUS SYSTEM. 
CONVULSIONS. 

This is a symptom and not a disease, and consists in a motor 
discharge evidenced by convulsive movements or contractures 
of the muscles of one or more parts of the body. 

Etiology. The nervous system of the child is so subject to 
reflex stimuli, and the inhibitory power of the brain is so poorly 
developed, that convulsions occur with comparative frequency. 
Among these stimuli are the toxins generated during the exan- 
themata or at their onset, toxins generated in the gastrointes- 
tinal tract, rachitis, phimosis, dentition and a host of other 
conditions may, actively reflexly, cause convulsions. When 
occurring during the first week or two of life the convulsion 
may be due to pressure on the brain from within, from a hemor- 



DISEASES OF THE NERVOUS SYSTEM 511 

rhage; later to an organic disease of the brain, as an abscess, 
hemorrhage, meningitis, etc. ) it may be due to an hereditary 
condition, epilepsy, or may be traumatic. Convulsions are 
much more frequent during the first two years of life. 

Symptoms. The convulsions may be the first evidence of 
trouble, or it may present many preliminary symptoms. ]^o 
two are alike, yet there are certain symptoms common to most. 

The seizure is usually ushered in by a preliminary cry, and 
the child at once develops tonic and then clonic convulsions of 
one or more parts or of the entire body. The head is thrown 
backward, and the back may be arched, the weight of the body 
supported by the back of the head and the heels, the condition 
of opisthotonos. The eyes are rolled, upward, and the pupils 
are dilated and fixed; there is a snoring respiration, spasmodic 
in character, due to the contractions of the diaphragm. If 
the convulsion lasts some time, deep asphyxia may be present 
The tongue may be bitten if protuded between the teeth of older 
children. Clonic or slight convulsions follow the tetanic ones, 
and when quiet the child falls into a sleep or a state of coma, 
to waken rational or to go without regaining consciousness into 
another more or less severe spasm. 

Prognosis. A single convulsion may give rise to no sequelse, 
but repeated ones are serious, as they may be the starting point 
of severe organic lesion of the brain, resulting in epilepsy. The 
prognosis depends very largely upon the cause of the condition. 
If due to the exanthemata there may be no recurrence, as early 
elimination removes the disturbing element. 

Treatment. The convulsive seizure must be controlled, and 
this can probably best be done by the inhalation of chloroform. 
The first thought of the mother and laity is to place the child 
in hot water, and much harm has undoubtedly been done by 
this procedure. The child is exposed unduly, and frequently 
burned, by too hot water being used, in the excitement. 

Of course in the absence of the chloroform the bath can be 
used. Oxygen inhalation is of great benefit. 



512 THE DISEASES OF CHILDREN 

The next indication is to remove the cause if possible. 
Because of the frequency of toxines from the intestine being 
the cause, at the first opportunity a dose of castor oil should be 
administered to completely empty the intestinal canal. A colon 
irrigation can be given with benefit. Rest and quiet are most 
essential. To prevent a recurrence the child is given one of 
the bromides, alone or with chloral hydrate (bromide of stron- 
tium, gr. V, with chloral, gr. iv), over a period of several days 
or a week or more. The general treatment of the underlying 
physical condition is important. If there is rachitis it must 
be given appropriate treatment, and child kept closely under 
observation. It should be kept away from school if of school 
age for an indefinite time. 

CHOREA. 

Varieties. Several varieties of this disease are recognized 
under the generic term of choreiform diseases, the variety, how- 
ever, usually indicated by the unqualified term chorea, is chorea 
minor, or acute chorea. 

The other varieties are chorea major, Huntington's or hered- 
itary chorea, habit chorea, electric chorea. 

CHOREA MINOR. 

Synonyms. St. Vitus dance; Sydenham's chorea; acute 
chorea. 

Definition. A neurosis, occurring almost exclusively in chil- 
dren before puberty, characterized by involuntary movements 
and twitchings of muscles or groups of muscles of the body. 

Etiology. There is unquestionably a close relationship be- 
tween this disease and rheumatism. Among the other diseases 
which bear a causal relationship are the exanthemata, tonsillitis, 
diphtheria. There may not be a distinct history of rheumatism, 
but of vague pains in the joints, which without close questioning 
would probably not be mentioned in the history. The occur- 
rence of heart lesions in chorea, reported by many observers, 
is a further confirmation of this theory. 



DISEASES OF THE NERVOUS SYSTEM 53^ 

The majority of cases occur between the ages of 10 and 15 
years. Girls, about the age of puberty, are prone to develop it. 
Unhygienic surroundings with poor food are predisposing 
causes frequently seen. Crowding at school, both as to the num- 
ber in the classes and the amount of work accomplished, may 
act as causes. Heredity is also a factor. Either a direct history 
of chorea in th« mother or a mother of an excessively nervous 
temperament may be elicited. Dr. AVeir Mitchell has claimed 
that a larger number of cases occur in the spring of the year. 
A sudden shock to the child, as a severe fright, may induce an 
attack. 

Pathology. 'No characteristic or constant change has been 
found in the nervous system in those cases which have been 
examined at autopsy. Among the changes reported by different 
observers are the following, vascular changes, as the result of 
an infection; cortical changes of an indefinite kind, chiefly a 
calcification of the ganglion cells (Golgi) ; connective tissue in 
the spinal cord and nerve centers (Garrod) ; hyaline degenera- 
tion of the nerve cells of the central ganglia (Elischer) ; hypere- 
mia of the brain and cord, and simple changes in the serous 
membranes. 

Symptoms. In the mild form of chorea there may be few 
or no prodromal symptoms, perhaps a short period of irritability 
or depression, in which the child cries easily and without provo- 
cation, followed shortly by a contraction or twitching of a group 
of muscles. This may evidence itself by a spasmodic winking 
of the eyes or jerking of the facial muscles, usually of one 
side, or a jerking or raisng of the arm or shoulder. The muscles 
of the hands soon become involved and the child drops articles 
without cause, it appears awkward at the table and handles 
eating utensils clumsily. If the lower extremities are involved 
it may walk jerkily, a peculiar gait, which is almost indescrib- 
able. The tongue is affected, even in the mildest form, and the 
speech may be halting or stammering and thick. This is espe- 
cially true if the muscles of the larynx are involved. 



514 The diseases of children 

The choreic movements usually cease entirely during sleep, 
and may do so even in the severe forms. 

Kelapses are very common. These may occur in a short time 
or a year or more may elapse between attacks. The duration is 
very variable, from a few weeks to several months, depending 
largely upon the time at which treatment is begun. 

Severe Chorea. This form is essentially like the mild, except 
in the extent of muscular involvement and the severity of the 
twitchings and contractions. 

One case under my observation was admitted to the female 
ward of the City Hospital during my service. She was a girl 
13 years of age, with a history of severe chorea for about a 
month. She had severe, general convulsive movements, with 
traumatic bed sores upon the heels, hips, elbows and shoulder 
blades. Until the contractions could be controlled it was neces- 
sary to put padded sides to the bed to keep her from falling 
upon the floor. Mild twitchings were present during sleep. 

Diagnosis. Posthemiplegic Chorea. Choreiform movements 
may follow the cerebral palsies of infancy. They are usually 
of one extremity. Contractures occur as a rule in this form, 
followed by paralysis of the part. Epilepsy, hysteria, habit 
chorea, must be borne in mind and eliminated by exclusion. 

Pericarditis may occur, but is rarely seen. 

Treatment. The first indication is to put the child to bed 
and at a complete rest, without a pillow, and with no book or 
other form of amusement. These patients invariably do better 
if removed from home, mother and friends, or if this is not 
possible put to bed at home, and in charge of a competent trained 
nurse, with family and friends excluded. This is very often 
difficult of accomplishment, and will be looked upon as inhuman 
and cruel by the average mother, but by firmness, yet with tact, 
it can usually be done. 

This complete rest and isolation does more toward obtaining 
a cure than any other form of treatment, medical or otherwise. 



DISEASES OF THE NERVOUS SYSTEM 515 

Some, and very often all, of the opposition to this rest may 
come from the patient, but it is nsually overcome in a few days. 

The diet should be simple, regular and nutritious. Milk 
should, perhaps, be the basis of the diet. 

Gentle rubbing or massage following a daily warm bath is 
a valuable adjuvant in treatment. In some cases the galvanic 
current is of benefit. 

Medicinally, no one remedy offers the same advantages as 
arsenic. A useful form is Fowler's solution, and it should be 
given in very gradually increasing doses, 1 drop a day at first, 
then 1 drop a dose from an initial dose of from 1 to 3 drops. 
If given in this way it can be increased to a much larger dose 
before physiologic effects are noted. 

In the case of the severe form referred to, the maximum dose 
reached, was 1 teaspoonful. It was then decreased in amount 
to 20 drops at the same ratio increased (1 drop each dose), at 
which time she was practically w^ell, was up and walking about 
the yard. 

Physiologic effects may show, as a pufiing of the eyelids, 
usually the lower, or gastric and abdominal pain, cramping in 
character. Both symptoms may not be present in every case. 

In one case, a boy of nine years, an inmate of an institution 
under treatment for his second attack of chorea, the arsenic was 
continued in increasing doses until 20 drops av as reached before 
physiologic symptoms were noted. Instead of decreasing at 
this time, as customary, the maximum dose was continued after 
the boy was dismissed from the institution infirmary. After 
taking the maximum dose for three weeks it was noticed he 
could not keep up in the school line because of a shuffling and 
hesitating gait. He was seen a few days later and a neuritis 
of both lower extremities found. This was evidenced by delayed 
sensation of the foot, partial paralysis of the legs, and the reac- 
tion of degeneration of the muscles below the knees under static 
electricity, after discontinuance of the arsenice he has greatly 
improved, but at the end of three months is still quite lame. 



516 THE DISEASES OF CHILDREN 

Symptomatic treatment in all cases is indicated. Attention 
to the bowels is very necessary, l^iglitly doses of aromatic 
cascara are usually of great benefit. Enemata may be indicated. 

In the severe forms, in which there is great muscular move- 
ment, the child must be controlled by the hypodermic admin- 
istration of morphia, the dose appropriate to the age. 

The temperature had best not be taken from danger of the 
thermometer being broken. 

The child should be kept from school for several months 
after apparent restoration of health. 

HEREDITARY CHOREA. 

Synonyms. Huntington s chorea; chronic chorea. 

Etiology. This form of chorea is rare. There is always a 
distinct history of heredity perhaps in one or two generations. 
It is not a disease of childhood, occurring usually after the age 
of 20. It may affect one or more in the same family, but may 
develop in a young child of a sufferer from this form. 

Symptoms. It is a disease of adult life, most cases occurring 
between 20 and 30 years of age. It is much like chorea minor, 
only the contractions are more severe, affecting chiefly the 
muscles of the face, arm and upper trunk, peculiar grimaces 
are made. Sooner or later a mental condition develops, which 
is much like dementia, following a short period of irritability 
and apathy. 

Prognosis. This is grave as to recovery. They may live 
years. 

Treatment. No treatment is of avail, the only recourse being 
confinement in an asylum or institution for the insane or feeble- 
minded. Symptomatic treatment is of course indicated. 

HABIT CHOREA. 

Sjmonym. Convulsive tic. 

Symptoms. This form of chorea occurs in the delicate and 
cachectic children, chiefiy in those children who can best be 



DISEASES OF THE NERVOUS SYSTEM 517 

described as '^spoiled." The only manifestation may be a 
twitching of a muscle of the face, contraction of one or both 
eyelids, raising the eyebrow, drawing down of a corner of the 
mouth, pulling down or up of one shoulder, contraction of the 
sternocleidomastoid muscle, pulling the head down and out, 
supinating or pronating the forearms, protruding the tongue, 
t\vitching of the fingers, etc. A starting point of this may be a 
binding of one of the articles of clothing, the shoulder for 
instance, being raised to relieve it of pressure. 

Diagnosis. This is not always easily made from a mild chorea, 
except by the oft-repeated contractions of the same muscle or 
group of muscles, a purposeful movement. 

Peterson describes a condition he describes as gyrospasms of 
the head, the head being rotated to the right or left many times 
per minute, and often accompanied by nystagmus. In these 
cases he found a history of rickets or intestinal irritation. 

Treatment. The cause should be searched for, if it is thought 
to be reflex. Ulceration of the nasal mucous membrane, eye- 
«train, phimosis, abnormalities of the ears and teeth, tight cloth- 
ing, irritating underclothes, may be a cause, and if present, 
removed. 

The diet should be controlled, sweets entirely eliminated, and 
regular meals insisted upon. J^o tea or coffee should be allowed. 
Removal from school until relieved. Proper rest and regular 
hours for sleep. Daily warm baths followed by a cool sponge 
if possible, and a vigorous rub, suggestion is of value in some 
cases. 

Medicinally, arsenic is of value, alone or best in combination 
with the bromides. General tonics are indicated very often. 

ELECTRIC CHOREA. 

This is a rare disease, so named because of the rapidity with 
which the movements follow one upon the other. They are 
violent as a rule. Dubini first described the condition in 1846. 



518 THE DISEASES OF CHILDREN 

The muscles of the neck and face are principally affected, 
but the arms and legs may also be involved. After var^dng 
duration of the active choreiform condition, the cases are de- 
scribed as developing atrophy and paralyses in the affected 
muscles or group of muscles, with perhaps complete paralysis. 
There may be pain and an elevation of temperature, the symp- 
toms, collectively, and the termination suggesting a severe 
intoxication. 

HYSTERIA. 

This is a comparatively rare condition in childhood, but occa- 
sionally seen about puberty or following this period. 

Etiology. A ^ ^neurotic" family history is usually present, 
and it occurs in the ^'spoiled" child, more often in girls. Over- 
crowding at school is a patent factor, fright, emotional and sen- 
sational plays and books may influence it. There is usually a 
history of the child being delicate, perhaps having had the exan- 
themata and other illnesses, a variable appetite, with not infre- 
quent digestive disturbances. 

Symptoms. These are usually divided into groups, according 
to the various systems involved, sensory, motor, mental or 
psychic. 

Sensory Manifestations. These symptoms may be manifested 
by hyperesthesia or anesthesia. The severity of the pain com- 
plained of at once is suggestive of the diagnosis. The slightest 
touch or even if the patient thinks it will be touched causes 
severe complaint. The location of the pain or point of tender- 
ness does not correspond to the distribution of the nerve supply- 
ing the part. Anesthesia, if present, usually involves half the 
body, and of itself is a suggestive occurrence. Anesthesia of 
one area or region may also be present. 

Photophobia may be present, or complete loss of sight in one 
eye or loss of vision to part of the eye. The visceral form of 
hysteria may be mentioned here. The patient may refuse food 
entirely, or if taken may shortly be followed by expulsive efforts 



DISEASES OF THE NERVOUS SYSTEM 519 

of the stomach and vomited without nausea. There may be 
diarrhea in this form also. Tympanites is often present. Hys- 
terical hiccough is encountered, and inability to swallow, with- 
out stricture of esophagus being present. 

Motor Manifestations. These are evidenced by a variety of 
convulsive movements which may affect the entire body or 
groups of muscles, one or both arms, or both legs, etc. Sensory 
symptoms may be present also. 

An 11-year-old girl was seen in consultation, who for three 
months had had severe ''convulsions,'' occurring principally in 
the forenoon. The mother was thin, anemic, subject of organic 
heart disease, and very ''nen^ous." When shown into the child's 
room the mother said, after we had talked for a few moments : 
''Have one of your spells now, you've had them this morning." 
Very shortly the child began with convulsive, up-and-dovm 
movements of arms and forearms, tightly clenched it hands 
together, moved up and down in bed, gave two or three long- 
drawn inspirations with its mouth tightly contracted and then 
relaxed, smiling shortly after. The knee reflexes were exag- 
gerated in this child. 

This is a sample of this type of hysteria. 

Hiccough is a frequent form of muscular contraction. Hys- 
terical aphonia is a common condition in hysteria, esophageal 
spasm being often associated. 

Mental or Psychic. Usually with either of the other group 
of symptoms there is a decided perverted mental condition, the 
child being extremely emotional. The phenomenon usually 
called hysteria is frequent, uncontrollable laughter followed by 
crying, or vice versa. Sacho terms an exaggeration of this con- 
dition hysterical mania, the child trying to do itself or others 
violence, being in a frenzy. Sympathy may precipitate such 
an attack. 

Diagnosis. If the motor symptoms are pronounced the 
trouble may have to be diagnosed from epilepsy. The child is 
in a condition of hysteroepilepsy. In this form of convulsive 



520 THE DISEASES OP CHILDREN 

attack there is no aura, the onset is gradual, there may be 
noises made throughout tlie attack, there is no impairment of 
vesical and rectal reflexes ; the attacks last much longer, fol- 
lowed usually by a condition of trance ; biting of the tongue is 
rare. 

Treatment. As in chorea, only the indication is even more 
pronounced, the first thing to be accomplished is to isolate the 
child from family and friends. This is far easier and better 
done by removing the child to an institution for the sick, and 
isolate it with a special nurse. The choice of a nurse is very 
essential. She should be firm, yet kind, and the child made to 
understand from the beginning that the nurse is in authority 
in the absence of the physician and absolutely in control. As 
soon as the acute symptoms are corrected the child should be 
placed under the care of a competent nurse or governess at home, 
and the same strict regime carried out at home. What teaching 
is done, must be at home and not at a general or private school. 
Later private schools are of benefit, with limited number of 
pupils, where individual attention can be given. 

Careful written directions must be given in regard to the 
whole life and routine of the patient, diet, dress, habits, cloth- 
ing, exercise and play. 

Suggestive therapeutics in these cases are of the very greatest 
help, and should be carefully and conscientiously employed. 

In some cases, in older children, especially where hysterical 
paralyses and joints are encountered, blisters and the actual 
cautery are of the most signal benefit. It may not be necessary 
to use them, their exhibition and explanation of method of 
procedure is usually all that is needed for a complete ^^cure." 
Cold douches to the back are also efiicacious. 

In the anorexia and vomiting, stomach washing and nasal 
feeding through tube, or gavage, usually brings prompt, favor- 
able results. 



DISEASES OF THE NERVOUS SYSTEM 521 

EPILEPSY. 

A functional disorder of the nervous system characterized by 
tonic and clonic convulsions at intervals, and attended by loss 
of consciousness. 

Etiology. There is no distinct etiology which is present in 
all cases. Heredity plays an important role in the etiology, a 
history of epilepsy, insanity or severe nervous disease being 
present in a majority of cases. Consanguinity, alcoholism, 
syphilis, are given as causes. Infantile cerebral hemorrhages 
are also a cause. Females are more often affected. The major- 
ity of cases occur between 5 and 15 years of age. Many reflex 
irritations are capable of precipitating the attacks as phimosis, 
dental irritation, intestinal inflammations, toxemias and intes- 
tinal parasites. Masturbation is also a cause. 

Pathology. But little which is definite is known of the 
pathology of this trouble, except in those cases due to cerebral 
hemorrhages. Degenerative changes have been found in the 
ganglion cells, hyperplasia of neuroglia tissues. Dana gives the 
chief change as an induration or sclerosis. 

Symptoms. Two types are generally considered, petit mal 
and grand mal. 

Petit Mal. In this form of epilepsy there may be no con- 
vulsions but a temporary loss of consciousness which, because 
of the pallor present, may be diagnosed as a fainting attack. 

The frequent occurrence of this phenomenon should arouse 
suspicion at once. The child may be at play and suddenly 
stop, and will sit, perhaps fall down ; its face will become pale, 
eyes staring and unconsciousness will follow for a brief or a 
much longer period. The respiration may be snoring in char- 
acter. When consciousness returns the child will have a dazed 
expression and not be able to recognize its surroundings. 
Usually there is no distinct aura, save, perhaps, a vague uneasi- 
ness felt by the patient, no preliminary cry and no involuntary 
passage of urine or feces. 



522 THE DISEASES OF CHILDREN 

Grand Mai. Iii tliis form, which is usually meant when the 
term epilepsy is used, several distinct stag^es are present, (1) 
aura, (2) cry, (3) tonic convulsions, (4) clonic convulsions, 
(5) unconsciousness. 

1. Aura or Preliminary Symptoms. Premonitory symp- 
toms may be felt by the patient for a number of hours before 
the active convulsive stage sets in. This may be only a feeling 
of giddiness, numbness, tingling, vague abdominal sensations, 
excitement or depression, aural or auditory symptoms. These 
warnings, if present always in the same form, enable the pa- 
tients to protect themselves from doing themselves bodity injury 
during the attack. 

2. Initial Cry. The cry which precedes the convulsive 
attack is usually quite pronounced. It may be hoarse and gut- 
tural, or a sharp, shrill cry, followed at once by the period of 
spasm and unconsciousness. 

3. Tonic Spasm. This may begin as a twitching of the 
facial muscles, the eyes are open and turned up, pupils dilated, 
conjunctiva in'sensible and face pale. The body is rigid, the 
arms and legs slightly separated and extended, the fists clenched. 
This stage, lasting less than a minute, is followed closely by the 
stage of 

4. Clonic Convulsions. Rythmic contractions of the mus- 
cles of the face, arms, legs and body begin, in the order named. 
There is stertorous snoring respiration, with accumulation of 
foamy saliva in the mouth, blood tinged, if the tongue is bitten, 
cyanosis of the face and lips. The sphincters may be relaxed 
with involuntary passage of urine and feces. 

The active convulsions continue for two or three minutes, 
and gradually subside ; cyanosis is followed by pallor, the pulse 
from being frequent and tense becomes feeble and slow, and 
the patient passes into the 

5. Stage of Unconsciousness or Coma. In this stage the- 
patient usually goes into a profound sleep, lasting often several 
hours, from which he is with difficulty roused, or the child may 



DISEASES OF THE NERVOUS SYSTEM 



523 



pass into a more or less natural sleep, lasting for a sliort time, 
and wakens in a dazed condition, not recognizing his surround- 
ings. A feeling of depression is usually felt for a day or so 
following. 

Diagnosis must be made from hysteria, uremia, Jachsonian 
epilepsy, or convulsions from reflex irritation: 



EPILEPSY. 


HYSTERIA. 


UREMIA. 


Aura 


none 


none 


Sudden onset 


excitement usually pre- 
cedes 


gradual 


Loss of consciousness 


none 


yes 


Pupils dilated, fixed; anes- 


not altered 


constructed without 


thesia conjunctiva, eyes 




anesthesia 


rolled up 






Tonic convulsion short du- 


rigidity but no convul- 


more condition of stupor 


ration 


sions 




Clonic convulsions various 




none 


parts body- 






Foam on hps, perhaps 


none. Do not bite tongue 


none 


bloody from biting tongue 






Involuntary passage from 


usually none 


none 


bladder and bowel 






Usually history of repeated 


as rule not as frequent 


none 


attacks. 




' 


Prolonged stupor following 


none 


none 


convulsions, may occur 


rare 


possible 


in sleep 







Urinary examination will reveal uremic nature of convul- 
sions. In Jacksonian epilepsy the convulsions are unilateral, as 
a rule, and perhaps affecting one leg or arm. 

Prognosis. Cases recover rarely. The duration, frequency 
and severity of attacks influence the prognosis greatly. The 
outcome is usually the development of dementia. 

Treatment. A careful investigation must be made to ascer- 
tain, if possible, any reflex cause, and that irritation removed. 
The various systems of the body should be reviewed and inves- 
tigated carefully: The eye, for refraction difficulties, muscle 



524 THE DISEASES OF CHILDREN 

irregularities; the nose, for deflected septum, tumors, polyps, 
catarrhal inflammation, etc. ; the mouth and gastrointestinal 
tract, for carious teeth, gastric insufficiency, dietetic errors, 
intestinal autointoxication or parasites, constipation or diar- 
rhea; genitourinary; phimosis, vesical irritation, kidney de- 
fects; the skin, for any lesions, etc., etc. 

The habits and life of the child should be inquired into care- 
fully, the diet regulated, hours of rest and sleep, form of exer- 
cise and play, ventilation of bed room, clothing, etc., must 
receive consideration. 

If the convulsive attacks are very frequent and severe, these 
patients do best in a home for epileptics where they are con- 
stantly under observation. 

In the control of the diet the method advised by Richet and 
Foulouse,* of withdrawal of salt from the food or at least a 
great diminution in its use, is worthy of trial, as excellent 
results have been reported from this simple procedure. It is 
reported that the convulsions are lessened in frequency and are 
much less severe. 

A large number of drugs have been advocated in the treat- 
ment of epilepsy, the most generally used, and I might say 
also, abused, being the bromides. The bromides are of unques- 
tioned value, but they also are capable of considerable harm if 
used indiscriminately. They do not cure the case, but do influ- 
ence the attacks, both in frequency and severity. Ten grains 
of any of this group or a combination of the different salts every 
three hours during the day, to a maximum daily dose of 50 to 
60 grains, will prove of benefit. The bromide of strontium is 
one of the most efiicacious of the salts. 

The fetid breath and bromide rash are evidences of satura- 
tion which indicates a discontinuance of the drug temporarily. 

During bromide administration careful attention to the 
bowels is most essential. The giving of arsenic to limit the 
skin eruption has been suggested. 

* Paris Academy of Science, November, 1889. 



t)ISEASES OF THE NERVOUS SYSTEM 525 

Confirmed epileptics do ixLuch better when segregated in a 
country home. 

DISOEDEES OF SLEEP. 

The new-bom infant sleeps 20 to 22 hours in the 24, unless 
disturbed from some cause. When from three to four months 
old, it lies awake longer periods at a time during the day, but 
should sleep all night, waking for but one feeding from 9 p. m. 
to G a. m. When six months old it should have no feeding 
at night, and sleep from 9 p. m. to 6 a. m. 

The chief causes of disturbance of sleep lie in the respiratory 
tract and the gastrointestinal canal. 

Catarrhal conditions of the nose, nasopharyngeal adenoids 
and enlarged tonsils which prevent the free passage of air into 
the lungs, cause great restlessness and loss of sleep. An elon- 
gated uvula may irritate the pharynx enough to cause an inces- 
sant coughing. 

Too frequent feeding, too rapid nursing, too hot or cold milk, 
prolonged breast feeding, will all cause discomfort, from indi- 
gestion, crying out in sleep and restlessness. 

It takes an almost incredibly short time for an infant to 
acquire bad habits of nursing, being held and rocked after 
feeding, etc., and a far greater length of time to correct these bad 
habits. Mothers and nurses are too often responsible for rest- 
less babies. The use of rubber napkins and failure to change 
the child through the night also cause restlessness. Imperfect 
ventilation, too little or too much cover may contribute to 
sleeplessness. 

Older children need the same routine of hours for feeding 
and bed as the infants. Until the child is six years old it should 
be fed a very simple supper and be put to bed before 7 o'clock. 
Keeping children up late or showing them off to visitors at all 
hours of the evening or night cannot be too strongly condemned. 

Telling exciting stories, threats of someone getting them and 
rlnrk rooms strike terror in the hearts of most children, and 



526 THE DISEASES OF CHILDREN 

may be the principal cause of nigiit terrors (pavor nocturnus). 
During one of these attacks the child has a wide-eyed stare, 
does not recognize those around, may cry out, and has hurried 
respirations. This condition may continue for some time, an 
hour or more, and the child fall into a deep sleep or waken 
crying, shortly to fall asleep again. As a rule it has no recol- 
lection of the occurrence on awakening in the morning. 

If often repeated the cause of the disturbance must be located. 
If the last meal at night has been too large it must be regu- 
lated ; no exciting stories or books or boisterous play should 
be allowed. 

The administration of a 5 or 10 grain dose of the bromides 
is indicated in certain cases in which control cannot be had 
of the case by eliminating the cause. 

OIiGAI!^IC NERVOUS DISEASES. 

Diseases of the Peripheral Nerves. 
There may be an inflammation of a group of the peripheral 
nerves, neuritis, or an involvement of the entire system of 
peripheral nerves, a multiple neuritis. 

MULTIPLE NEURITIS. 

Etiology. An intoxication of the system with invasion of the 
nerve tissue with microorganisms, is the active cause, but 
exposure to wet and cold, trauma or pressure are predisposing 
causes most frequently met with. 

Pathology. Inflammation and degeneration may be present 
in this condition, and occur in the same nerve at different points. 
Pathologically, can be recognized inflammation of the sheath, 
the endoneurium interstitial neuritis or the nerve tissue itself, 
parenchymatous neuritis. In the latter type the destruction is 
so great that the condition is like a degeneration, if not identical. 
If the degeneration is very extensive and severe there may be 
an entire destruction of the nerve tissue, leaving nothing but 
the sheath. Secondary degeneration is the form which usually 



DISEASES OF THE NERVOUS SYSTEM 527 

takes place iii the peripheral nerves. If the cells in the anterior 
horns of the cord degenerate there is degeneration also in the 
motor nerves. Regeneration may take place in degenerated 
nerves. 

Symptoms. The typical type of this form of nenritis is that 
caused by the toxin of diphtheria. It is rare in infants, but a 
number of cases have been reported in children from five years 
up. Lead poison has been given as a cause. 

Th onset is sudden, there are pains and sensitiveness in the 
extremities, chiefly the lower; fever may run high, 103° to 
104° F. The child is extremely weak, and imable to stand. 
The pains continue, the muscles begin to atrophy and paralysis 
sets in. The reflexes are diminished or lost entirely. Hyperes- 
thesia followed by anesthesia may occur, the latter being due 
both to pain and heat. Some of the muscles of the eye and throat 
may be paralyzed. Regurgitation of food is present w^hen the 
latter occurs. There is wrist drop and foot drop in the general 
form, ^o reaction takes place to the rapidly interrupted cur- 
rent, and the reaction to the galvanic current slow. 

Prognosis. Regeneration of the nerve tissues generally takes 
place and recovery occurs. 

The prognosis depends somewhat upon the extent of the loss 
of electrical reactions. If the reaction of degeneration is com- 
plete the prognosis is more grave, as far as entire restoration of 
function is concerned. 

Treatment. Complete rest in bed is the first indication. Pain 
being one of the first and chief symptoms it is the first to 
demand attention, if not relieved by the application of heat 
and must be relieved by an anodyne. Heroin, codeine or one 
of the coal-tar products can be used, the latter, however, with 
caution. Phenacetine is perhaps the safest. Heat is a help 
in obtaining comfort, best applied moist. Calomel as an initial 
remedy is indicated. Strychnia in the affected muscle has been 
given. Among the drugs suggested are the following : Fl. ext. 
ergotol, oi to 3ii ; sodii salicylatis, gr. x, q 3 h. 



528 THE DISEASES OF CHILDREN 

Electricity is of great service, the galvanic current being the 
form to use at first, but only after the acute symptoms have 
subsided. After a month or six weeks, with improvement the 
faradic current is indicated in connection with massage. 

FACIAL PALSY. 

Synonym. BelVs Palsy. 

In this form of neuritis the seventh nerve is involved. 

Etiology. Infection, exposure to cold, rheumatism, middle- 
ear inflammation, pressure by forceps blades in instrumental 
delivery^ are given as causes. If central, the process may be 
due to a meningitis. 

Symptoms. The first symptom may be pain and tenderness 
under the lobe of the ear at the point of exit of the nerve, fol- 
lowed very soon by paralysis of motion of the muscles of one 
side of the face. 

The characteristic signs of Bell's palsy are the inability to 
close the eye on the affected side, the eye rotating upward when 
attempting to do so, inability to pucker the mouth as if to 
whistle, and a defiection of the tongue from the median line. 
If the acute symptoms do not last very long the prospects for 
entire recovery are good. Atrophy of the muscles soon follows. 

Diagnosis is chiefiy to be made from lesions of the brain, which 
is usually easy, as paralyses of the extremities, one or both, are 
apt to be present. 

Prognosis. The majority of cases recover, practically with 
entire restoration of function of the muscles. The duration 
is from six weeks to five months. • Continued reaction of degen- 
eration renders the prognosis less good. 

Treatment. In all cases the use of cathartics is indicated, 
with rest in bed or on the bed while the pain under the ear lasts. 
A small fly blister, one-half inch square, placed at the point of 
exit of the nerve is of benefit. 

After the acute symptoms have subsided the weak galvanic 



DISEASES OF THE NERVOUS SYSTEM 529 

current is used very gently, and just strong enough to contract 
the muscles. 

If there is much contracture of the mouth, the strain on the 
cheek can be relieved by bending soft wire with a small hook 
at the end for the mouth, the other end going up and hooking 
over the ear. 

The administration of iron, salicylate of soda and soda and 
arsenic may give good results. 

OBSTETRICAL PARALYSIS (eRb's). 

These palsies take their name from the fact that they appear 
after manipulations during labor. The lesion is one to the 
brachial plexus of nerves and occurs when the head is pulled 
sharply to one side, or traction is made with the fingers in the 
axilla, in an effort to deliver the shoulders. It very rarely 
occurs, about once in 2000 labors, and a small percentage of 
the cases are bilateral. 

The paralysis usually manifests itself about the third or 
fourth day after birth. The child may move its forearm and 
hand, but makes no effort to move the arm from the body. At 
first, however, the whole arm is limp and motionless. 

If there is no improvement the deformity noticed is a slight 
inclination forward of the affected shoulder, an atrophy of the 
muscles of the upper arm and shoulder, and tendency to an 
inward rotation of the arm so the thumb points rather back- 
ward instead of forward. The paralysis is flaccid in type, and 
there is no tendency at all to a spastic condition. 

There is a characteristic electric reaction from a loss to the 
faradic current to a complete reaction of degeneration. 

In birth palsies, of cerebral origin, the palsy is rarely limited 
to one arm, a hemiplegia being more common. The paralysis 
is apt to be spastic in nature, and convulsions may occur. 

Prog-nosis. This varies according to the extent of the patho- 
logic condition, which is evidenced by the electrical reactions. 
If the faradic response is gone but the galvanic retained, even 



530 THE DISEASES OF CHILDREN 

if but feebly, recovery may take place; if response to both 
currents is gone the recovery, if it takes place at all, will be 
greatly retarded. 

Treatment. ISTothing is indicated during the first two or three 
weeks. At the end of this time gentle rubbing, not deep mas- 
sage, should be begun, with gradually increasing passive motion. 
At the end of six to eight weeks, a very weak electricit}'' is 
applied, using the current with which a reaction can be obtained. 
This is applied once a day or every other day, at first Rve min- 
utes, then ten minutes at a time. 

DISEASES OF THE SPINAL CORD. 
INFANTILE PARALYSIS. 

Synonyms. Infantile spinal paralysis; poliomyelitis anterior 
acuta. 

Etiology. It was first described in 1840. From the fact 
that this form of spinal disease occurs in epidemics, from the 
clinical symptoms, sudden onset, etc., the strong possibility is 
that it is due to a specific organism, though none has been iso- 
lated. There is a possibility also that the causative agency is 
a toxin. Trauma has been regarded as a cause, but it plays 
small part in the etiology, ^o micrococci have been isolated 
from the cerebrospinal fluid. It occurs more frequently from 
one to three years. It may occur in more than one member of 
a family. 

Late investigators'^ claim to have transmitted the disease to 
monkeys. They conclude that the virus must be of protozoon 
nature. 

Pathology. Any section of the cord may be involved, the 
lumbar region perhaps most frequently, the cervical next in 
frequency. The process occurs chiefly in the anterior horns, and 
it may vary from a simple congestion to an inflammation. This 

*Landstemer and Popper: Ztschr. f. Immimitatsf. u. Exp. Therap. 1909. 
ii, 377. 



DISEASES OF THE NERVOUS SYSTEM 531 

part of the cord has the most active blood supply, and it has been 
pointed out by different observers that the primary changes are 
in the blood vessels, and the degeneration which occurs in the 
ganglion cells are entirely secondary. As a result of this degen- 
eration, the ganglion cells may disappear entirely, and the 
process may extend to the entire gray matter, it shrinking in 
size, and the "white matter also shows such tendency. The 
affected muscles show a characteristic change, many muscle 
fibers disappear entirely and the others are shrunken, the whole 
limb being atrophied, even the bone being smaller than that of 
the unaffected side. 

Symptoms. Epidemics of infantile paralysis are most fre- 
quent in the summer months. Starr^ has collated 4:4: epidemics 
of infantile paralysis. Individual cases may and often do 
develop during an attack of acute gastrointestinal infection. 
It may also occur as a sequel to one of the exanthemata, partic- 
ularly scarlatina. It is more often seen in the robust, and if 
not associated with other diseases is like an infectious disease 
in its onset. The child may awaken in the night, after being 
restless during the night or perhaps listless during the previous 
day, with vomiting and fever to 102° to 104° F., and in those 
so inclined, even with convulsions. Pain is referred to the back 
and to the affected muscles. The acute symptoms last two or 
three days, when the paralysis is noted. Fever may continue 
for a week. Diarrhea often is seen. The skin is very active. 

The part affected varies with the section of the cord involved, 
the arms or legs being paralyzed. The muscles of the legs are 
affected most frequently, chiefly the peronei group, the upper 
extremities less often. In the upper extremities the following 
muscles show the paralysis oftenest, extensor muscles of the 
forearm, except the supinator longus, the deltoid, biceps and 
brachialis anticus. The internal muscles are affected more 
often than the external, and the anterior more often than the 
posterior. 

* Journal American Medical Association, vol. li, no. 2. 



532 THE DISEASES OF CHILDREN 

The paralysis is of the flaccid type, without contractures, 
associated very soon with atrophy, the electric reactions are 
altered, the sensation is not greatly impaired though it may 
be tender and the reflexes diminished or lost in the affected 
limb. The affected part is cold and often cyanosed. 

The paralysis at first may involve the entire extremity, and 
as the inflammation or congestion subsides restoration of func- 
tion in all but a single muscle or group of muscles takes place. 
This is a characteristic symptom of infantile paralysis. 

The atrophy is progressive until the difference in the two 
sides is quite marked. 

The electrical reaction is that of complete degeneration, com- 
plete loss of faradic and galvanic response in the nerves, and 
delayed galvanic response in the muscles. 

Diagnosis. The chief condition which may be confused with 
infantile paralysis is cerebral meningitis, but the convulsions 
of infantile paralysis occur only at the onset, and none of the 
other meningeal symptoms are present. 

In the acute cerebral palsies the chief diagnostic symptom 
is the spastic nature of the palsy, without atrophy; its hemi- 
plegic nature ; the normal electric reaction, with not infrequent 
involvement of the mind. The reflexes in the cerebral type are 
exaggerated also. 

In neuritis the pain is a prominent symptom, which is usually 
absent in poliomyelitis, but in other respects the symptoms are 
much the same, viz., paralysis, atrophy and electrical phe- 
nomena. 

Prognosis. The mortality in sporadic cases is small, and in 
epidemics from 6 to 10 per cent. There is no way of giving 
an accurate prognosis in the beginning of an attack, as often a 
very hopeless looking case will show regeneration of a number 
of muscles which at flrst showed complete paralysis. The fam- 
ily should, however, be put in complete possession of the facts, 
and the possible outcome, emphasizing the favorable symptoms 



DISEASES OF THE NERVOUS SYSTEM 533 

always. A number of cases have been reported showing com- 
plete recovery. 

Treatment. In the acute stage dry cups along the spine is 
beneficial. Hydrotherapy is of great benefit. In this stage an 
anodyne is needed for the pain unless it continues to improve. 

'Not much improvement can be looked for for several weeks, 
when an evidence of regeneration will show by return of func- 
tion in some muscles. Improvement may be had by administra- 
tion of urotropin, gr. v, every four hours, to child of eight years 
(Gushing). Salicylate of sodium or strontium can be used to 
advantage. 

With the first evidence of contracture of opposing muscles 
enough to cause deformity, a brace should be so applied as to 
overcome this, or a tenotomy of the opposing muscle, if it is 
very great before the brace is applied. 

Massage is of very great service after the acute symptoms 
have begun to subside, to exercise the fiaccid muscles. Electric- 
ity is to be used for this purpose also, using that form of current 
which will cause the muscle to contract. It should not be 
applied oftener than once a day, 10 or 15 minutes at a time. 

Much has been accomplished in the last few years in the 
treatment of marked deformities in the transplantation of ten- 
dons, for the technic of which the reader is referred to any 
of the late works on surgery. 

ACUTE MYEI.ITIS. 

An inflammation of the entire substance of the cord, in a 
transverse section, or over an extensive area. 

Etiology. This is essentially an acute infection, occurring 
independently or as a sequel to one of the acute infectious dis- 
eases or exanthemata. It may also result from an extension 
downward of a primary meningeal lesion. Trauma, resulting 
in pressure or hemorrhage into the cord from an injury may be 
causes. The causes given in the adult form, as alcohol, lead, 
mercuiy, etc., can practically be eliminated in children. 



534 THE DISEASES OF CHILDREN 

Pathology. There is no regularity in the extent of involve- 
ment or limitation of the segments involved, as two or more 
portions of the cord may be affected with normal tissue between. 
The dorsal portion has been found most often involved. The 
chief, and perhaps primary, changes are in the blood vessels, 
the blood supply is interfered with and softening occurs. The 
meninges are congested and SAvollen. The white and gray matter 
are not distinct. The cord substance is destroyed and is soft 
and creamy in consistence. The process described extends to 
the nerve roots also. 

Symptoms. These vary greatly, and because of the variety 
in symptoms the cases have been grouped into acute, subacute 
and chronic forms. 

In the acute form the onset is sudden, and if of septic origin 
it begins with a chill and fever, usually above 102° F. There 
is pain in the back, varying with the site of the lesion. Tender- 
ness is also present. If there is an entire transverse inflamma- 
tion the function of all muscles below this level are interfered 
with, including the sphincters. If the upper part of the cord 
is affected the arms are also paralyzed. Sensory symptoms are 
also present, complete anesthesia extending to a level of the 
lesion. All sensations are absent, and the patient does not 
feel as if the extremities were a part of him. 

If the lesion is in the cervical portion of the cord the par- 
alysis of the arms will be flaccid and. of the lower extremities 
spastic in character. If the lower portion of the cord is affected 
the paralysis is of the lower extremities and is of the ffaccid 
type, with loss of reflexes but without involvement of the arms. 
The loss of sensation will extend to the upper limit of the 
lesion. Trophic lesions will often develop in these cases, with 
development of bed sores. If these are large and absorption 
from them possible, the temperature will be influenced. 

In male children priapism may be present in lumbar involve- 
ment, and in all cases disturbances of bladder and rectum take 



DISEASES OF THE NERVOUS SYSTEM 535 

place. Involuntary passages of urine and feces frequently 
occur, tliough retention is perhaps more frequent. 

Diagnosis. The clinical picture presented is fairly typical 
of this form of lesion. In hemorrhage into the cord the onset 
of the trouble is more sudden, without fever and without loss 
of reflexes, atrophy or reaction of degeneration. The pain is 
not so great, if present at all, in hemorrhage. 

In multiple neuritis, if all extremities are involved, the par- 
alysis is the same, while in myelitis the paralysis is flaccid in 
the upper and spastic in the lower extremities. 

Prognosis. A guarded prognosis should always be given. The 
more extensive the involvement and acute the symptoms the 
graver the prognosis. The early development of complications, 
as bed sores, cystitis, etc., make the prognosis graver. 

In the subacute variety, regeneration may take place to some 
extent in the cord, and restoration of function to a certain extent 
be possible. 

The younger the child the graver the prognosis. 

Treatment. The child will usually have been put to bed when 
first seen. If a young child, positive orders must be given that 
it be not taken from the bed and held or rocked under any 
circumstances. 

Local application of cold by a long ice bag is of service and 
should be applied intermittently. The tendency to trophic dis- 
orders should be remembered, and the long-continued applica- 
tion not allow^ed. The bladder and bowels must be closely 
watched. Extra precautions must be taken if catheterization 
is needed. The position of the child must be changed often and 
the skin of the dependent parts closely guarded against bed 
sores. Most careful attention must be given the bed sore if 
the skin breaks down. Ichthyol ointment, 3 or 5 per cent, or 
balsam of Peru (M. xx) and castor oil (gi) are good dressings 
in these cases. A water bed or air mattress may prevent the 
development of bed sores. 

If improvement is shown the child must be carefully watched 



536 THE DISEASES OF CHILDREN 

to keep it from using the affected parts. Judicious massage 
and rubbing should be used for exercise. 

Tonic treatment is indicated, and if contractures develop, 
tenotomy and the proper orthopedic measures used to prevent 
and correct them. 

pott's disease. 

'No attempt is made to describe the condition of Pott's disease 
from the standpoint of the orthopedic surgeon, but only as 
relates to the changes it produces in the spinal cord. It is a 
fairly common condition in childhood, and is due to a tuber- 
cular osteitis. 

Owing to softening of the bony and intervertebral cartilage an 
angulation takes place in the spinal column, its lumen is nar- 
rowed and pressure is made on the cord. Yet it is surprising 
how great the deformity may be without any pressure symp- 
toms presenting. The inflammatory condition from the bone 
extends to the meninges and thence to the cord, or pressure 
symptoms may present from the meningeal involvement alone. 

The cord may be softened and degeneration of the cord is 
found above and below the point of pressure. Much the same 
condition is present as in myelitis. 

Symptoms. The development of this condition is very slow 
as a rule. Spastic paralysis is an early symptom and may be 
the first noted. Sensitiveness and pain are present when pres- 
sure is made, due to involvement of the nerve roots. Disturbed 
sensation may also be present. 

Diag^nosis. This is to be made principally from myelitis. 
A careful examination of the spine for deformity or rigidity 
should always be made in cases of suspected spinal cord lesion. 
In Pott's disease there is pain on pressure over the involved 
vertebra. In those rare cases in which the paralysis precedes 
the deformity the diagnosis may be difficult. 

Prognosis. If the paralysis is entirely due to the pressure, 
with but little inflammation present in the cord, the process 



DISEASES OF THE NERVOUS SYSTEM 537 

may be stopped by proper orthopedic measures, taken to relieve 
the deformity and pressure, by properly fitting appliances. 
However, the case is apt to be progressive, and the outlook for 
recovery very grave. 

Treatment. The first positive indication is to relieve the 
pressure by prompt orthopedic measures. Perhaps rest in bed, 
entirely recumbent, may influence the condition, or in other 
cases plaster of Paris jackets are indicated. 

Fresh air tonics, good food and hygiene are the chief indica- 
tions other than the surgical ones. 

TUMOES OF THE SPINAI. CORD AND ITS COVERINGS. 

These growths are very rare in childhood. Syphilis and 
tuberculosis cause the majority. Malignancy may be the cause. 
Cj^sts and gliomata are also given as causes, the former due to 
hemorrhage. 

Symptoms. The onset is very gradual, the symptoms varying 
according to location of the tumor. If the meninges are prin- 
cipally involved there is pressure on the posterior roots and 
pain later after involvement of the meninges and roots takes 
place. ^KTot infrequently only half of cord may be involved. 
The cervical and dorsal regions are perhaps most often affected. 
There is flaccid paralysis of one or both arms Avhen located high 
up, and of the legs when lower in the cord. Atrophy soon 
develops in each. 

Diagnosis. In Pott's, disease the deformity is usually present 
and the course of the disease is longer. In myelitis the course 
is much more rapid, pain is not so prominent and paralysis 
sooner. 

In neuritis paralysis is present earlier and the rectum and 
bladder not involved. 

Prognosis. This is unfavorable, as surgery offers but little 
hope. In syphilitic tumors some good may be accomplished by 
proper treatment. 

Treatment. Except in syphilitic tumors, drugs are of no 
avail. The iodides and mercury should be tried in every case. 



538 THE DISEASES OF CHILDREN 

but their efficacy is doubtful. Operation for removal of tbe 
tumor should be performed if all other remedies fail, though 
it is an operation with but little hope of relief, and most diffi- 
cult to perform. 

SYPHILIS OF SPINAL CORD. 

The infant, the subject of hereditary syphilis, is apt to de- 
velop this condition more often than if it is acquired. 

Pathology. An involvement of the arteries is the most fre- 
quent lesion, an endarteritis or arteritis causing softening of 
the cord substance, as in myelitis. A meningitis is present, 
also gummata in the cord and brain. 

Symptoms. These are not like those present in conditions 
just described. The onset is gradual; the paralyses follow a 
period of weakness of the muscles and inability to walk, and are 
more apt to be of the spastic variety. Pain or anesthesia, or 
both, are present, var^dng according to the involvement of the 
roots. Reflexes are usually increased, sphincteric reflexes may 
be interfered with. 

Usually there is an irregular distribution of the disease over 
the greater part of the cord. The dorsal enlargement is most 
often and severely affected. The process spreads irregularly 
to other portions of the cord, evidenced by irregular areas of 
loss of sensation here and there on trunk and extremities. 

Diagnosis. This is chiefly from myelitis. The history of 
syphilis or its occurrence in other parts of the body is an aid 
in diagnosis. In myelitis a whole cross-section of the cord is 
involved, and symptoms are the same on both sides below the 
level of the lesion ; in syphilis the invasion of the cross-section 
of the cord is slow. Erb's statement that in syphilis there may 
be complete paralysis with but slight anesthesia and slight 
rigidity should also be remembered. 

In infantile spastic paraplegia the early appearance of the 
trouble and the absence of particular sensory symptoms makes 
the diagnosis clear. 



DISEASES OF THE NERVOUS SYSTEM 539 

Infantile paralysis sliows no pain, and even in the irregular 
distribution of tlie paralysis, as the. right arm and left leg, the 
absence of sensory symptoms rules out syphilis. 

Treatment. Mercurials and iodides are positively indicated, 
and the earlier they are given the better the prognosis. In the 
child the inunction of mercury is the best method of administra- 
tion, with gradually increasing doses of the iodide of potash. 
Fifty per cent ung. hydrargyri, with vaseline or lanolin, can 
be used, rubbing a piece the size of a small ha^el nut into the 
flexures and groin once daily. 

With the development of acute coryza the iodides should be 
discontinued temporarily, and when resumed, at the minimum 
dose, and again increased as before. 

DISSEMINATED SCLEROSIS. 

Synonyms. Multiple cerebrospinal and insular sclerosis. 

According to one observer (Fotzke) this disease may be man- 
ifest at birth or develop during the first year, but the larger 
number of cases are seen during the second decade. 

Etiology. The infectious diseases are considered the most 
frequent causes. Among the other causes may be mentioned 
trauma, heredity and metallic poisoning (Oppenheim). 

Pathology. There are irregular patches of sclerosis at vari- 
ous points in the central nervous system, brain, pons, medulla 
and cord. The growth is of fibrous tissue, an increase in neu- 
roglia tissue. Some changes take place in the blood vessels. 

Symptoms. Following a brief period of weakness of the 
lower extremities, and sometimes the upper, there develops an 
intention tremor which is very noticeable. It is only present 
when the patient wills to make a movement, and in an effort to 
accomplish it the tremor takes place. The tremor becomes so 
marked that the patient cannot feed himself or drink from a 
glass held in one or both hands. E'ext develops a difliculty in 
speech, which has been designated scanning speech. He speaks 
very slowly and deliberately. 



540 THE DISEASES OP CHILDREN 

The eye sjinptoms are fairly characteristic. Nystagmus 
develops early, especially when looking from one side to the 
other. The visual field is narrower. 

The mind becomes affected rather early. Hysterical attacks 
are common, memory is bad. 

The lower extremities develop a spastic paralysis, which 
greatly interferes with walking. 

There are no distinct or typical electrical reactions, the 
sphincters are not involved and, as a rule, atrophy of muscles 
does not take place unless there is sclerosis of the anterior horns, 
which occurs less frequently. 

Diagnosis. In myelitis^ sphincter relaxation and sensory phe- 
nomena are prominent symptoms. 

The association of the usual symptoms, intention tremor, 
scanning speech, mental symptoms and spastic paralysis are 
sufficient to make the diagnosis. 

Prognosis. The condition is incurable and it is essentially 
a chronic disease. 

Treatment. The patient should have a protracted rest in 
bed as soon as the diagnosis is made, especially if there is a 
decided intention tremor. General tonic treatment is of benefit, 
including hydrotherapy, electricity and massage, all intelli- 
gently applied. 

HEREDITARY ATAXIA. 

Synonyms. Friedreich's disease; family disease of the cord. 

Etiology. This is essentially a disease of early life, develop- 
ing in the majority of cases before the tenth year. It is believed 
by some to be primarily due to an arrest of development of the 
cord. It may occur in several generations, and often several 
are affected in the same family. 

Pathology. The process is principally located in the posterior 
and lateral columns, and the entire cord is smaller than normal. 
The process is principally a sclerosis, either located entirely in 
the column of Goll or the columns of Burdach or both, and gen- 
erally the entire length of the cord is affected. 



DISEASES OF THE NERVOUS SYSTEM 541 

Symptoms. Generally the first symptom, if it is not present 
at birth, is a peculiar gait, the child being unsteady and awk- 
ward on its feet. It balances itself with feet separated, and the 
gait is much as it is in locomotor ataxia. Following this man- 
ifestation in the lower extremities, a spastic condition develops 
in them, and a loss of power in the upper extremities and a 
jerky movement of them when an attempt is made to grasp or 
pick up an object. Xystagmus may be ^^resent at this time also. 
The child talks thickly and later cannot be understood. Sensa- 
tion is rarely interfered Avith. Deep refiexes are not present 
as a rule. 

Deformities develop after the spastic stage sets in, particu- 
larly in the feet, the great toes being hyper extended, the other 
toes to a lesser degree. 

Mentality is much interfered with as the disease progresses. 

Diagnosis. Tabes resembles this form of ataxia, but it is 
practically never seen in children. In multiple sclerosis, the 
intention tremor and marked spastic gait are diagnostic signs. 

Prognosis. These cases grow progressively worse until they 
are completely helpless, but life is often prolonged for years. 

Treatment. Xothing can be done to influence the course of 
the disease. The patient can be made comfortable by attention 
to hygiene, diet, etc., and correction of deformities by section 
of contracted tendons, etc. 

HEREDITARY SPASTIC PARALYSIS. 

A condition occurring as a family characteristic, in which 
there is a spastic paralysis chiefly affecting the lower extrem- 
ities, more rarely the upper. 

Cases present different symptoms according to the chief loca- 
tion of the pathological lesion, cerebral or spinal, or a combina- 
tion of both. 

In the spinal type the chief symptoms are spastic paraplegia, 
with contractures and increased reflexes, and the pathologic proc- 



542 THE DISEASES OF CHILDREN 

ess is located in tlie pyramidal tracts of the lateral columns. 
In this type there is no evidence of cerebral involvement. 

In the cerebral type the first symptom to call attention to 
abnormality is an arrested cerebral development. If the disease 
develops early the child will not show the normal intellection 
of its age, or if older will soon develop idiocy. Blindness is 
often present. They are classed under the term amaurotic 
family idiocy. If of the cerebrospinal type the spastic condition 
above referred to develops in addition to the idiocy. 

Diagnosis. The hereditary nature of the disease is character- 
istic. In congenital paralysis there is a history of convulsions, 
and usually of a difficult labor, and no hereditary history. 

Prognosis. These cases may live for years, but the outlook 
for recovery of mind is hopeless. 

Treatment is entirely of no avail, and is symptomatic. 

PROGEESSIVE MUSCULAR DYSTROPHY. 

A condition in which there is a progressive muscular weak- 
ness of a certain group of muscles ; associated with atrophy. 

Etiology. This is a family disease. Several members being 
often affected, the transmission being through the mother. 

Pathology. The pathology is chiefly in the muscles, the 
fibers being atrophied, the sheath being often filled with fat. 
The spinal cord and nerves are normal. In the pseudohyper- 
trophic form there is also an increase in fat between the fibers 
and an increase in the connective tissue. 

Symptoms. Three types are generally described, pseudo- 
hypertrophy of the muscles; juvenile type (Erb's) ; and Land- 
ouzy-Dejerine's type. 

Sachs* has given the following tabular description of the 
three : 



* Sachs: Nervous Diseases of Children. 



DISEASES OF THE NERVOUS SYSTEM 



543 



TYPES OF PRIMAKY DYSTROPHIES. 



MUSCULAR 
PSEUDO- 
HYPERTROPHY 



JUVENILE FORM OF 

PROGRESSIVE TYPE LANDOUZY- 

MUSCULAR ATRO- DEJERINE 

PHY (eRB'STYPE) 



Part first affected Legs (calves). Shoulder girdle Face andshoul- 

! der girdle. 

Distribution of hypertrophy . Calves, rarely Muscles around None. 

thighs. shoulder gir- 

dle and pelvic 
girdle. j 



Distribution of atrophy Thighs, deep Thighs, deep Face muscles, 

muscles of including lips 
back, upper and orbicu- 
arm. Hyper- laris palpe- 
trophied parts b r a r u m ; 
may become shoulder and 
atrophic in la- scapular mus- 
ter stage. cles. 



Parts remaining normal . 



muscles of 
back, shoul- 
der, and scap- 
ular muscles. 
Calves during 
later period; 
at that time 
also general 
atrophy. 



Face, forearm. Face, forearm, Forearm, hand 
and hand, ex- hand and leg and legs, and 
cept in last muscles ex- deep muscles 

cept i n last of back. 

stages. 



In the Landouzy-Dejerines type the principal groups of 
muscles involved are those of the face and shoulder girdle. The 
first muscle to atrophy is the obiculario oris, followed by the 
other facial muscles and of the shoulder girdle. 

Erb's type begins in late childhood, before puberty, and 
involves the muscles of the shoulder girdle, including the del- 
toid, the pelvic girdle and the back. Because of atrophy of the 
muscles of the back, the child stands with a decided arch in 
the back and lordosis, the shoulder blades are thrown backward 
and the shoulders forward. 

The legs are affected late in the disease. 



544 



THE DISEASES OF CHILDREN 



In the 'pseudohypertrophic form the principal change is in 
the calf of the legs and thighs. As the name implies, there is 
a decided increase in the size of the legs and thighs, with a coin- 
cident loss in power. The gait is a peculiar waddling one. 




FIG. b5 FIG. 56 

TYPICAL ATTITUDES ASSUMED BY PATIENT WITH PSEUDO-HYPERTROPHIC 
MUSCULAR PARALYSIS. * 




FIG.. 57 



When sitting on the floor characteristic positions are assumed 
in attempting to get upon his feet. With the assistance of his 
hands he climbs up himself, gradually assuming the erect 
posture, with the lordosis present, standing with feet wide apart. 
When prostrate upon the floor he cannot rise. When the muscles 

* Cuts reproduced through the courtesy of Dr. Frank L. Christian, Ehnira, 
N. Y., and The Medical Era. 



DISEASES OF THE NERVOUS SYSTEM 



545 



of the arm and forearm are involved the same hypertrophy 
takes place here. 

Prognosis. As to cure, this is grave. Arrest of the disease 
has been reported. 

Treatment. The general tonic treatment is indicated, with 
massage, electricity, hydrotherapy, etc. 




FIG. 58 



DISEASES OF THE MENINGES AND BRAIN. 



MENINGITIS. 

Several varieties of meningitis are named, simple acute men- 
ingitis; tubercular meningitis; cerebrospinal meningitis, with 
numerous subdivisions according to the part involved and the 
etiology. 

SIMPLE ACUTE MENINGITIS. 

Etiology. This form of trouble is essentially due to an infec- 
tion, either during the so-called infectious diseases, typhoid 
fever, pneumonia, the exanthemata, influenza, nephritis, etc.. 



546 THE DISEASES OP CHILDREN 

to trauma or to emboli of a septic nature and middle-ear trouble. 
The pneumococcus, streptococcus and staphylococcus are the 
most frequently found organisms. 

Pathology. The chief inflammatory changes are in the pia 
mater, followed by a change in the dura. The greatest involve- 
ment is at the base, principally the posterior portion. The 
serous membrane is red, thickened, dull and rough, covered with 
fibrin; this stage is followed by one of effusion, at the base or 
in the ventricles. This may be serum, or according to the in- 
fecting organism, purulent in character. 

Symptoms. A short period of indisposition may be present, 
the nature of which is not even suspected with gradiial develop- 
ment of the symptoms, or it may begin with a convulsion, high 
fever and rapid pulse. There may also be severe headache, vom- 
iting of the projectile type, loss of sleep, restlessness, photo- 
phobia and rigidity of the neck. The convulsions may be 
repeated. The temperature is usually high, 104° F., but may 
average 101° F. or 102° F. Coma may be prominent. Opis- 
thotonos may occur shortly before death or in one of the 
convulsions. 

The duration is usually from ten days to three weeks, or even 
much longer. 

Prognosis. This is grave. Recovery sometimes occurs, but 
the diagnosis is often questioned closely before admitting the 
correctness of it. 

Diagnosis. Differential diagnosis from tubercular and epi- 
demic cerebrospinal meningitis considered later. In the pres- 
ence of convulsions as the primary symptoms, the diagnosis 
should not be made until the various intoxications, as intestinal, 
etc., are eliminated, as they can be usually in a few days, at the 
most. 

Treatment. Absolute quiet, in bed, in a darkened room. 
Purgation, preferably by calomel followed by a saline, if pos- 
sible, and the application of an ice bag to the head, at the base, 
sides and top, if possible. Hydrotherapy for the temperature 



DISEASES OF THE NERVOUS SYSTEM 547 

and the administration of bromide and chloral for the control 
of the convulsions and restlessness. 

Liquid, perhaps predigested, nourishment and attention to 
the kidneys is important. 

TUBERCULAR MENINGITIS. 

This may be a local manifestation of tuberculosis or a sequel 
to an infection elsewhere. 

Etiology. This disease is due to a direct invasion of the 
meninges by the tubercle bacillus. The bacilli may localize 
in the meninges as a primary affection, absorbed, perhaps, from 
the nasal mucous membrane direct ; or they may be carried 
through the lymph or blood from tubercular foci elsewhere, the 
lungs, lymph nodes, joints, abdomen, etc. Lack of resistance 
from previous illnesses is usually present as a determining fac- 
tor. There may be a history of previous attacks of enterocolitis, 
bronchitis, bronchopneumonia, the exanthemata, middle-ear dis- 
ease, from which the child never fully recuperated. 

Age is an important factor in the etiology. Children are 
much more often affected, especially between the ages of two 
and ten. 

Pathology. The pathological changes vary greatly. Autopsy 
findings may be very slight in the severe and rapidly fatal 
cases, and the protracted ones may show severe lesions. 

The hrain may show changes which vary from a few scat- 
tered grayish tubercles along the vessels at the base, to a thick, 
inflammatory exudate over the entire base. The effusion may 
be thin and seropurulent, and extend into the fissures of the 
Drain and well up on to the convexity. Accumulation of fluid 
in the ventricles is usually found, distending them fully. The 
process may extend into the cord. 

The lungs may show unresolved areas of pneumonia, perhaps 
with cheesy disintegration, the bronchial glands are also en- 
larged and some broken down or softened. The mesenteric 
glands are usually enlarged, perhaps disintegrated or softened. 



548 THE DISEASES OF CHILDREN 

The superficial lymph nodes may be found enlarged, also the 
tonsils. 

Symptoms. But few diseases present so varied a picture at 
the onset as tubercular meningitis, and in consequence the diag- 
nosis in the majority of cases is not made during the early 



The onset is always insidious except in a very few cases in 
which convulsions may usher in the attack. For a very varying 
length of time the child is not normal, is listless and peevish, 
restless at night, no appetite, and if old enough may complain 
of headache. N^ausea may be present with slight gastrointes- 
tinal disturbance, sufficient to look upon it as the cause of the 
indisposition. There is a slight rise of temperature, more or 
less continuous and without decided remissions. In one case 
seen in an adjoining city recently, because of the fever, a 
tentative diagnosis had been made of malaria, and later of 
typhoid fever. After a few days the vomiting may be a prom- 
inent symptom, recurring often and without provocation. Con- 
stipation is the rule in this stage. 

After a varying length of time, rarely longer than two weeks, 
the signs of acute inflammation take place, and the diagnosis is 
plain. There is a rise in the temperature to 108° F. or 104° E. 
I have not seen the temperature very much above 104° F. in 
this form of meningitis, though 106° F. has been often reported. 
Before this time the patient could be roused, often with diffi- 
culty, but from now on there is more or less deep stupor, from 
which it cannot be roused. It will swallow when liquids are 
placed between the teeth, but later cannot do this. 

At the beginning of this stage, for a brief period usually, 
the characteristic symptom, Cheyne-Stokes' respiration takes 
place. In two of my cases recently, this symptom was present 
early in the inflammatory stage for 24 hours and disappeared, 
returning a few hours before death in one of them. 

The pulse is very variable, at times rapid, at others slow, 
being also irregular in volume. 



DISEASES OF THE NERVOUS SYSTEM 549 

Vasomotor phenomena are present, alternate flushing and 
blanching of the cheeks, and the tache cerebrals is usually pres- 
ent at this time. 

The abdomen is retracted, as a rule, giving the typical 
"scaphoid belly.'' The pupils are usually unequally dilated 
and fixed, though they may be equal. The conjunctival reflex 
is absent and a squint may be present. 

There may be general convulsions at this stage, or only slight 
convulsive movements of the facial muscles and the extremities. 
Rigidity of the neck usually develops early, and as the disease 
progresses there may be opisthotonos more or less marked. 

From this time the child develops into the stage of coma; 
the pulse is very rapid, the respirations shallow and irregular, 
the sphincters relaxed. The temperature just before death may 
rise very rapidly, but usually does not. 

Death, which is inevitable, may be preceded by general 
convulsions. 

The duration is very varied, lasting from one to six weeks, 
with an average perhaps of three weeks. 

Diagnosis. The chief aid in the diagnosis of the form of 
meningitis present is a consideration of the previous personal 
and the family history of the child. 

Acute meningitis usually develops suddenly, and all of the 
symptoms are more acute from the onset, shorter in duration, 
and with higher temperature. 

The low, continuous fever is suggestive of typhoid, and in 
suspicious cases the Widal and diazo tests should be made, and 
if still uncertain at the end of the second week, repeated. 

Lumbar puncture may be of great assistance in clearing up 
the diagnosis (see page 510). The fluid is then examined for the 
tubercle bacilli, pneumococci, staphylococci, etc. 

Prognosis. The positive diagnosis of a case of tubercular 
meningitis is the equivalent of signing of the death certificate 
in advance. If a case of meningitis recovers in which the diag- 



550 THE DISEASES OF CHILDREN 

nosis of the tubercular form has been made the original diag- 
nosis was in error. 

Treatment. This is purely symptomatic, and of no avail as 
far as a cure is concerned. Chloroform for control of the con- 
vulsions, with bromides and chloral; liquid diet; ice bag to 
head and spine; stimulants when indicated, etc. 

EPIDEMIC CEREBEOSPII^AL MENINGITIS. 

Synonym. Spotted fever. 

As the name implies, this form of meningitis occurs epidemic- 
ally, and is due to the specific organism, the diplococcus inter- 
cellularis. Dr. J. Lewis Smith wrote of the first case having 
occurred in the United States in 1806, since which time epi- 
demics have occurred in all parts of the country. 

Etiology and Bacteriology. The specific organism causing 
the disease is the diplococcus intracellularis or the meningo- 
coccus. It is described* as of slight viability on all media, 
agar, to which has been added sheep serum and 2 per cent 
glucose, being found the best, cultures were kept alive five or six 
days in this way. It is supposed to gain entrance to the system 
through the nasal mucous membrane, through the upper respira- 
tory tract to the blood stream, or a direct infection through the 
lymph channels. 

Experimenting with guinea-pigs, the following conclusions 
were reached: (a) Cultures freshly isolated are more virulent; 
(h) cultures attenuated by artificial growth cannot be rejuve- 
nated by passage through animals; (c) autolysis of an attenuated 
culture may yield an extract which may be used as an adjuvant 
to increase the activity of other cultures; (d) quantities of cul- 
tures injected vary little in effect; (e) guinea-pigs respond 
relatively very poorly. The nasal mucous membrane has been 
demonstrated to be a carrier, and hence a disseminator of the 
meningococcus. 

* Flexner: Journal American Medical Association, vol. li, no. 4. 



DISEASES OF THE NERVOUS SYSTEM 551 

It occurs both in adults and children, cases as young as three 
months having been reported; Rotch* reports one case in an 
infant 24 hours old. 

Pathology. The gross pathological changes are much like 
those in other varieties. There is an intense hyperemia of the 
meninges of brain and cord, which is followed by an exudate 
of thick seropus. The entire surface of the brain and cord is 
covered with the exudate, which also extends in the fissures of 
the brain, and between the pia and the cortex, and the ventricles 
may contain a large amount of fluid. The meningococcus is 
found in the cells and exudate, and larger numbers of poly- 
morphonuclear neutrophiles than lymphocytes are found. There 
is a high leucocytosis. 

Symptoms. The onset is as a rule abrupt, but the diagnosis 
cannot be made on the first day of illness. Vomiting, followed 
by a chill or rigors and high temperature and very often con- 
vulsions, are among the early symptoms. Headache is con- 
stant; there is pain in back and neck and early delirium is 
frequent. Backward retraction of ^the head and back occur 
early. The vomiting at this stage is projectile in character. 
The whole picture is one of an overwhelming infection from 
the beginning. The fever ranges between 102° and 104° 'F., 
but may go very much higher. Reflexes are exaggerated. 

A characteristic symptom is the development of an eruption 
on the body, hemorrhagic in character, at first petechial, then 
larger bruise-like areas. Herpes is found on lips and face. 
Kernig's sign is usually present. 

Coma may develop early. Otitis media is sometimes present 
as a result of an early infection of the middle ear. Purulent 
conjunctivitis is often present, also corneal, bulbar and con- 
junctival anesthesia. Maier'sf observation of muscle soreness, 
especially in the lumbar, erector spinas, thigh and upper arm 
muscles, is a valuable sign. 

* Archives of Pediatrics, October, 1908. 

t Royer: Archives of Pediatrics, October, 1908. 



552 



THE DISEASES OF CHILDREN 



Several types are seen in the same epidemic, the fulminant 
and rapidly fatal cases, which die within two or three days ; 
the milder cases, in which the symptoms are not nearly so 
severe, and those cases which are very mild and of short 
duration. 




FIG. 59. A BOY OF THIRTEEN LYING IN THE USUAL POSITION OF THOSE ILL 
WITH EPIDEMIC MENINGITIS.* 




FIG. 60. PHOTOGRAPH OF A BOY 10^ YEARS OLD, TAKEN 5 DAYS AFTER 
THE ONSET OF EPIDEMIC MENINGITIS, SHOWING OPISTHOTONOS. 



Prognosis. This, under former methods of treatment, has 
varied in different epidemics. Mortality was from 25 to 75 
per cent, while now, under the serum treatment, the recoveries 
have been 75 per cent. Dunnf reports a mortality of 19 per 
cent in 40 cases treated with the serum. Hence early diagnosis 

* Reproduced through the courtesy of Dr. B. Franklin Royer, Philadelphia, " 
from the Archives of Pediatrics, October, 1908. 
t Archives of Pediatrics, October, 1908. 



DISEASES OF THE NERVOUS SYSTEM 553 

and treatment are very necessary. Flexner* states tliat so long- 
as the diplococciis is still present in tlie exudate from the spinal 
canal, and the mechanical damage to the anatomic structnre is 
not irreparable, the employment of the serum holds out hope 
of considerable benefit. As a result of serum treatment soon 
after injection, the diplococci tended to be greatly reduced in 
numbers, to disappear from the fluid part of the exudate, to 
become wholly intracellular, to present certain changes in 
appearance, as swelling and fragmentation, and to stain dif- 
fusely and indistinctly, and coincidently to lose viability in 
culture. 

The exudate in the meninges rapidly loses turbidity under 
influence of serum injections. 

Functional restoration of meninges is certain even where 
exudate has been purulent. Unfavorable indications after sev- 
eral injections of serum are progressive, increase in turbidity 
of exudate and rise in leucocytosis and greater persistence of 
the diplococci with retention of viability. Relapse is attended 
or ushered in by increased exudation of leucocytes in meninges, 
higher systemic leucocytosis, and reappearance of or increase 
in the numbers of diplococci; although they may not regain 
power to grow outside the body in cultures. 

Eelapses during treatment are not very frequent, and rarely 
has a case terminated fatally during relapse when the treat- 
ment with serum has been resumed without delay and vigor- 
ously pushed. The recovery in serum-treated cases is in the 
great majority of instances complete. The number of compli- 
cations is small, deafness being a persistent defect. 

Diagnosis. This is best cleared up by use of the lumbar 
puncture and examination for the specific organism. Injection 
of the fluid in guinea-pigs may be necessary to clear up the 
diagnosis. The occurrence of a second or third case in a vicin- 
ity is often suflicient to make the diagnosis. 

* Loc. cit. 



554 THE DISEASES OF CHILDREN 

Counting and differentiating the cells in the cerebrospinal 
fluid is of great assistance. In this type the polymorphonuclear 
cells predominate largely; in the tubercle forai the predomi- 
nating cells are lymphocytes, and they are few, and tlie fluid is 
much clearer. 

Treatment. The serum treatment of this disease, with the 
serum discovered by Flexner, is the only one which offers any 
hope of cure. Of 393 cases reported by Flexner there was a 
recovery of Y5 per cent. 

The signs of improvement in the case are shown usually 24 
hours after the injection. 

To Flexner is due the credit of developing the serum treat- 
ment of this disease. He describes the action and administra- 
tion of the remedy as follows : The action of the serum is anti- 
toxic and bacteriolytic, and is brought into contact with the 
germs by injection into the cerebrospinal canal after as much 
cerebrospinal fluid as possible has been drawn off. 

The serum is harmless and has brought about a decided 
reduction in the mortality in the disease, from 80 per cent to 
less than 30 per cent. After the first injection the number of 
meningococci free in the fluid outside the cells are decreased, 
after the second or third injection those in the cells are de- 
stroyed and the amount of fluid is less. The serum should 
always be given by the subdural injection, never subcutaneously. 

Lumbar puncture should be performed in every suspicious 
case at once, and if the fluid is turbid 20 to 30 cc. of warmed 
serum injected. The fluid withdrawn must be examined for 
the organism, and if found the injection repeated daily until 
symptoms are improved. Forty-five cubic centimeters are 
recommended as the maximum dose of the serum, governed 
somewhat by the amount of resistance to the serum as it is 
injected. Doses of 30 cc. are necessary for good results. The 
dose should be repeated daily as long as diplococci are found in 
the spinal fluid. At least four daily doses should be given, 
even if the diplococci disappear earlier. In fulminant cases 



DISEASES OF THE NERVOUS SYSTEM 555 

the injection can be given oftener than once in 24 hours. Re- 
appearance of diplococci is indication for repeating injections. 
As a result of the injections the temperature drops in from 
3 to 12 hours, and the other symptoms improve, especially the 
headache and delirium; pain and hyperesthesia are relieved, 
coma is lessened, intelligence slowly returns and nourishment 
is taken. The strabismus and Kernig's sign are more persist- 
ent. The polymorphonuclear leucocytes in the fluid increase 
in number after the first injection. 

ACUTE ENCEPHALITIS. 

This is an inflammation of the brain tissue itself. 

Etiology. Any of the acute infectious or contagious diseases 
may be the exciting cause of this condition. Influenza, the 
exanthemata, diphtheria, pertussis, pneumonia, erysipelas, ul- 
cerative endocarditis and the acute septic diseases may be 
causes. 

Pathology. The primary condition is hemorrhagic, the in- 
flammatory areas surrounding these spots, round-cell infiltra- 
tion and degeneration take place. 

Symptoms. It occurs in young children and is preceded by 
a short period of depression, restlessness and headache. Con- 
vulsions may precede the active symptoms. There is fever up 
to 104° F. or 105° F., rapid pulse and shallow, hurried breath- 
ing, which becomes irregular or Cheyne-Stokes, as the disease 
progresses. 

Motor and sensory symptoms develop according to the area 
most involved. Rigidity of the neck is present early, paralysis 
or hemiplegia may present, ocular palsies often develop; deaf- 
ness is usually present early, and if recovery takes place the 
hearing is not reestablished. 

Prognosis. This is very grave, but varies according to the 
extent of involvement of the brain. If some remission in the 
symptoms is noted by the end of the first week the prognosis 
is more favorable. 



556 THE DISEASES OF CHlLDitEN 

Treatment. Absolute rest; calomel purgation, ice to head 
and spine, and a blister to the cervical, region of the spine. 
Supportive and sedative treatment may be indicated at differ- 
ent times. 

HYDROCEPHALUS. 

This is an accumulation of cerebrospinal fluid either in the 
subdural spaces or in the ventricles. It may be congenital or 
acquired, primary or secondary, acute or chronic. 

ACUTE HYDROCEPHALUS. 

Etiology. Trauma may be a factor, and it probably is of 
microbic origin, though nothing definite is known of its cause. 

Pathology. Inflammation of the brain or meninges, venous 
or lymphatic stasis may be present. The accumulation of fluid 
in the ventricles may continue and be so great as to cause thin- 
ning of the brain from internal pressure. A condition known 
as meningitis serosa may exist, following trauma or infectious 
diseases. 

Symptoms. Slight fever may usher in the condition, con- 
tinuing a few days and gradually subsiding, with perhaps a rise 
at a later date. Headache is one of the earliest of the sub- 
jective symptoms, associated w^ith retraction of the neck, and 
probably opisthotonos. Bulging of the fontanelles takes place. 
Headache, blindness, stupor and coma may be present. As the 
fever drops to normal all of these symptoms may be relieved 
for a short period, and again come on as the temperature rises. 
There may be no improvement, but the child succumbs to intra- 
cranial pressure. The opposite may obtain, the symptoms 
growing less in severity and the child finally recovering. Symp- 
toms are sometimes relieved by lumbar puncture, and nothing 
abnormal is found in the fluid. 

Prognosis. This depends largely upon the cause of the con- 
dition and its severity. Cases do recover in which the diagnosis 
is positive. Recovery or amelioration of all symptoms but the 
blindness may occur. In general the prognosis is unfavorable. 



DISEASES OE THE NERVOUS SYSTEM 557 

Treatment. Lumbar puncture is indicated and should be 
repeated if the effects of the first have been good. This treat- 
ment gives the only hope of cure, as no medication is of avail. 

CHRONIC HYDROCEPHALUS. 

The typical form of this variety is the congenital type, though 
a further subdivision is made by some authorities. 

Etiology. The cause of the congenital form is not known. 
I delivered a child at term with an enormous hydrocephalus^ 
in which the cord was wrapped tightly around the neck three 
times, enough pressure being exerted to make a deep groove in 
the neck in which the coils of cord rested. 

It occurs where both parents are perfectly healthy, and not 
infrequently it is the first-born so affected, and later children 
are perfectly normal. Mother and daughter have been known 
to have a hydrocephalic first-born. Syphilis, alcoholism, tuber- 
culosis, in the parents have been given as causes. 

In this form the head is enlarged at birth and may be the 
cause of dystocia. It continues to enlarge after birth, ^ot 
infrequently associated with the hydrocephalus is an imperfect 
closure of the spinal canal, spina bifida, or one of the varieties 
of talipes. 

Enormous accumulation of fluid may take place in the ven- 
tricles, distending them and compressing the brain until it is 
greatly attenuated. 

Th.e sutures are widely separated, especially the frontal, 
coronal and sagittal, and the fontanelles are very large and 
bulging. 

Symptoms. The first thing noticed in these infants is the 
very high, bulging forehead, with an upward tilting of the 
eyes and a tendency to exophthalmos. As the fluid increases a 
nystagmus is apt to begin. There may be a stationary period in 
which the head does not enlarge, and the child may be able to 
hold it up without special support, but as the fluid increases 
in amount the head cannot be raised from the pillow or turned. 



558 THE DISEASES OF CHILDREN 

It is often surprising the amount of intellection exhibited 
in these cases, which at autopsy show such thinning of brain 
tissue. 

A case which was under my observation when an interne at 
the New York Infant Asylum was admitted during the service 
of Dr. L. Emmet Holt, and through whose courtesy the case 
was reported in the American Practitioner and Neivs, January 
2, 1892. 

She was the fourth child of healthy, German parentage ; head 
large and soft, with bulging fontanelles at birth. At the age 
of one month the head measured 19 inches in circumference, and 
while under observation the gain in circumference was at the 
rate of half an inch a week. 

There was a divergent strabismus, axis of eyes turned upward, 
pupils active and followed light; no contractures, rigidities or 
convulsions. 

The child died at the age of four months, and the head was 
24-J inches in circumference, 16 inches from ear tip to tip, and 
from occipital protuberance to bridge of nose, 20 inches. Eighty- 
eight ounces of fluid were withdrawn by a trocar. The brain 
in its thickest portion at the base varied from ^ to -J inch in 
thickness. There was free communication between the lateral 
ventricles and the third ventricle at the base. The medulla, 
pons and cerebellum appeared normal. There was no evidence 
of meningitis or tumor. 

Diagnosis. This must be made from rachitis, and should be 
easy. The enlargement of bone at the centers of ossification, 
the other bony changes, headsweats, etc., make the diagnosis of 
rickets easy. 

Prognosis. This is always serious and a guarded opinion 
should be given, even where there is an apparent improvement 
in the case in intellection and stationary growth. 

Treatment. This is entirely symptomatic and palliative, as 
no medicine which may be given can cause an absorption of the 
fluid. 



DISEASES OF THE NERVOUS SYSTEM 559 

Drainage of the fluid by tapping the ventriries through the 
f ontanelles or by lumbar puncture may prr ve efficacious in 
some cases, and should be repeated if found so. 

CEBEBEAL PALSIES OF CHILDHOOD. 

Synonyms. Spastic hemiplegia; spastic paraplegia. 

Etiology. The most frequent and potent factor in the cause 
of these conditions is a much-delayed labor, and in the first-born, 
very often. Asphyxia at the time of birth may play a part in 
its causation. Injury to the mother during the last weeks of 
gestation may be a cause. 

Heredity should be considered. There may be a distinct 
history of similar children affected in the parents' family. 

The acute exanthemata may act as a cause of the acute palsies. 
Trauma after birth may also act as a cause. Convulsions and 
whooping-cough may give rise to pathologic conditions in the 
brain which would result in spastic paralysis. 

Pathology. In those cases being present at birth, more severe 
lesions are generally found, as a porencephaly, defective devel- 
opment of the brain or parts of it; meningeal hemorrhages; 
cysts ; thrombosis or embolism, meningitis or encephalitis, scler- 
osis, hydrocephalus, and failure of development of the cortical 
cells. 

Symptoms. Usually three types are described, according to 
the body area involved, viz. : Cerebral spastic hemiplegia ; spas- 
tic paraplegia. 

The symptoms vary according to the time of development. 
If it occurs directly after birth there may be convulsions, coma 
and cyanosis. In those developing later, convulsions mark the 
onset. Many cases appear during the first year of life, and 
fully two-thirds, perhaps more, begin in the first three years of 
life. Convulsions may recur at fairly regular intervals for 
some time after their onset. 

The paralyses are at first flaccid, but they rapidly become 
spastic, the paralyzed side remains smaller and undeveloped. 



560 I'HE DISEASES OJ^ CHlLDK]t2N 

When of the leg, there is a decided limp and spastic gait. Some 
contracture is nearly always present. Athetoid movement may 
be seen of the face and upper extremities. 

Electrical reactions are normal, reflexes increased, ankle 
clonus and the Babinski reflex are present. 

The face is sometimes involved, a facial palsy being present 
in a certain number. Aphasia is nearly always present, and is 
motor in type. 

Epilepsy has been described as being part of this trouble. 
Choreiform movements may develop in the course of the disease. 
Idiocy is one of the marked symptoms, it developing in a short 
while after the onset of the trouble. 

In quadriplegia all four extremities are in\rolved, extensive 
injury to the brain probably having taken place. All of the 
symptoms in a hemiplegia are present in this form, only more 
severe. 

In paraplegia only the lower extremities are involved, and 
the lesion is very apt to be at the apex of the brain. 

Diagnosis. The spastic character of the paralysis, the dimin- 
ished intelligence, age of patient and history of the onset is 
usually sufiicient to make a diagnosis. Reflexes are normal or 
exaggerated in contradistinction to other similar conditions 
having no reflexes. 

Prognosis. This is unfavorable, but cases do show an im- 
provement when severe form of paralysis was present early. 
The early development of failing intellection is grave. Repeated 
convulsions make the outlook bad. If no improvement takes 
place in the contractures, the prognosis is not so good. 

Treatment. Owing to the idiocy, these cases do best where 
they are under constant surveillance, hence the importance of 
confining them at a public institution, if possible. 

Proper hygiene, diet and general supervision of the life of 
the child is necessary. Orthopedic surgery is indicated always, 
where large amount of contractures are present. 



DISEASES OP THE NEKVOUS SYSTEM 561 

TUMOES OF THE BRAIIs" AND MENIITGES. 

Tumors of the brain are comparatively frequent in ehildliood. 
Peterson has reported 335 cases as follows: 

TABLE I. 
Form of Tumor. No. of Cases. 

Tubercle - 166 

Glioma 42 

Sarcoma 37 

Cyst 35 

Carcinoma 11 

Gliosarcoma , . . 5 

Angiosarcoma 1 

Myxosarcoma 1 

Papillary epithelioma 1 

Gumma ,' 1 

Not stated 35 

Total 335 

TABLE II. 
Site of Tumor. No. of Cases. 

Cerebellimi 105 

Pons Varolii 42 

Centrum ovale 41 

Basal ganglia and lateral ventricles 30 

Corpora quadrigemina and crura cerebri 25 

Cortex cerebri 23 

Medulla oblongata 7 

Fourth ventricle 6 

Base of brain 8 

Total 287 

Tubercular tumors are more often met than any other variety, 
and the cerebellum the most frequent site of tumors. 

Etiology. With the exception perhaps of gliomata, tumors 
of the brain are secondary to growths of like character else- 
where in the body. A glioma may result from an injury or 
blow. 

Pathology. The tubercle may occasion a variety of growths 
and affect any part of the nervous system. It occurs as a soli- 



562 THE DISEASES OP CHILDREN 

tarj tubercle or as multiple tumors, and tuberculosis in other 
parts of the body, as the lung, mesentery, etc., is the starting 
point of the infection. They vary in size very much, from a 
pea to one which occupies a greater portion of the brain. These 
tumors are as a rule encapsulated, and may show softened areas 
in the center on section. Bacilli may be demonstrated, and in 
this way differentiate it from other varieties of tumor. 

Glioma is a growth which is found beneath the gray matter 
in the white matter, as a rule, though it may involve the latter 
also. It is a slower growth than the others. An increase in 
the blood supply is present in the areas involved in this growth. 
The mass is not encapsulated, and is much softer than the sur- 
rounding tissue. 

Cysts are quite frequently encountered — frequently found in 
brains when least expected. The origin of these cysts was evi- 
dently a hemorrhagic or other process occurring in infancy. 

Gumma may occur in hereditary syphilis, but is rare. 

Symptoms. These may be considered from the standpoint of 
the intracranial pressure and cerebral localization of the growth. 

AVe believe that these growths are very frequently not diag- 
nosed on account of the vagueness and indefiniteness of the 
symptoms. They vary greatly according to the rapidity of the 
growth, the amount of intracranial pressure from it, coincident 
increased blood supply, and hydrocephalus which follows. 

Among the general sympionis may be mentioned : 

Headache. This may be the most striking symptom, both 
as to its severity and persistence. 

If the meninges are involved it will be more severe and 
localized, perhaps associated with tenderness. Nausea and vom- 
iting, in connection with a more or less continuous headache, 
in a child is a suspicious occurrence. The vomiting, if pro- 
jectile, is quite characteristic of brain involvement, and later 
it occurs without nausea and irrespective of food. 

Convulsions, in connection with headaches, are suspicious, 
and especially so if the projectile vomiting is also present. 



DISEASES OF THE NERVOUS SYSTEM 563 

Optic neuritis, from the intracranial pressure, is an early 
symptom, perhaps preceded for a short time with swelling of 
or choked disc. Blindness is not uncommon. Only one side 
may be involved, nsually it is double. A careful ophthal- 
moscopic examination of the eyes should be made in all sus- 
picious cases. 

The pulse at the end becomes rapid and weak, and not infre- 
quently the respirations show the typical Cheyne-Stokes' type. 

Localization Symptoms. This is a special study in itself, and 
the reader is referred to any late text-book on nervous and 
mental diseases for a detailed description of these diagnostic 
methods. 

Diag^nosis. From abscess by the presence of fever, and pos- 
sibly sweats in the latter. Abscess also forms more quickly, and 
previous history, perhaps of middle ear or frontal sinus disease, 
which are suggestive. 

In tubercular meningitis which is prolonged the diagnosis 
may be difficult. Headache is usually more severe in meningitis. 

Progfnosis. This is extremely grave no matter what the char- 
acter of the growth, and even if diagnosed surgery offers very 
little hope of cure. Gummata, one of the least frequent forms 
of growth, may yield to specific treatment. 

Treatment. Surgery is practically the only form of treat- 
ment which offers any hope of relief, and the outlook is exceed- 
ingly grave, even with skilled surgery children bear operative 
measures on the brain badly. The coal-tar products, with 
caffeine and codeine, may have to be tried for the relief of 
the headaches. The bromides and chloral are of service in cer- 
tain cases, and the regulation of the diet most essential. 

Because of the disseminated form of the growth of glioma 
and sarcoma, operations for their removal are not as successful 
as in other forms. 

ABSCESS OF THE BRAHq". 

A much more frequent condition in children than in adults. 
Etiology. The most frequent cause is a preceding middle- 



564 THE DISEASES OF CHILDREN 

ear or mastoid suppuration. Trauma is also a frequent cause, 
and disease of tlie nose and frontal sinuses may be mentioned. 
Venous infection and lateral sinus involvement in middle-ear 
disease is the most frequent method of involvement. 

Pathology. Rarely, small, walled-off collections of pus may 
be found postmortem which were not previously suspected. 
Larger collections of pus may be walled off, others show no 
distinct limiting membrane. It may be located in any part of 
the brain, beneath the dura or external to it entirely. A num- 
ber of the pus-producing organisms may be found in the pus 
in these abscesses. They occur most often, perhaps, in the 
frontal and temperosphenoidal. 

Symptoms. Abscesses located deep in the brain tissue may 
cause no symptoms unless they are large enough to give symp- 
toms of intracranial pressure. They are difficult of diagnosis. 
Following operations on the middle ear or mastoid, the diag- 
nosis is much easier. Headache, vomiting, irregular fever and 
rigors, drowsiness, coma or convulsions are a train of symptoms 
which are convincing. Cerebral localization, as in brain tumors, 
must be brought into consideration if the site of the abscess is 
to be diagnosed. 

Diagnosis. If a history of previous inflammations contiguous 
to tbe brain is obtainable, the diagnosis is easier. 

From solid tumors, the presence of rigors and irregular tem- 
perature is a diagnostic sign. 

In meningitis and inflammation of the lateral sinus, the 
onset is much more sudden and the range of temperature higher. 
In meningitis, in addition, there is apt to be retraction of the 
head and rigidity of the neck. 

Prognosis. This is extremely grave. It is influenced by the 
location, size and duration of the abscess, and its accessibility 
for surgical intervention. 

Treatment. Prophylaxis is of importance in ear and nasal 
disease, especially of suppurating variety. Prevention of ex- 
tensive involvement by early paracentesis is indicated in all 



DISEASES OF THE NERVOUS SYSTEM 565 

cases. Free and radical operation in mastoid abscess is the best 
treatment. 

Brain abscess can be treated successfully only by surgery, 
and careful exploratory operation, done when the condition is 
localized. 

INTRACKANIAI. HEMORRHAGE. 

Hemorrhage within the skull of the new-born may be sub- 
dural, or within the brain substance, cerebral. 

Etiology. This may be due to the general hemorrhagic diath- 
esis or disease, or if it is present at birth due to causes existing 
during labor, either long-continued pressure during the second 
stage, trauma of forceps delivery, or forcible extraction in breech 
presentations of the after-coming head. 

Symptoms, A large hemorrhage, subdural in character, may 
be present at birth or occur shortly after, in which event the 
child is either still-born or asphyxiated. A hemorrhage is the 
most frequent cause of convulsions in the new-born. These are 
more often localized and not general. A hemorrhage of sufficient 
size to cause these symptoms is usually enough to cause the 
death of the child. If the hemorrhage is slow the pressure 
symptoms will not be so severe and the child may live some time, 
and a condition of cerebral atrophy will develop. 

Cerebral hemorrhage is more often seen in older children, 
and may occur as a complication of the infectious diseases. The 
hemorrhage causes a period of sudden unconsciousness, followed 
by a paralysis more or less extensive, according to the area in- 
volved by the compression. Recovery may take place, but 
rarely. 

Prognosis. In subdural hemorrhage, if the primary asphyxia 
is relieved, the child may recover, to be afflicted with one of the 
cerebral palsies later. 

Treatment. Artificial respiration is used to overcome the 
primary asphyxia. Great discretion should always be used in 
labor as to when interference is justifiable, to intelligently choose 



566 THE DISEASES OF CHILDREN 

between the evils resulting from prolonged labor and those 
which follow instrnmental delivery. In competent hands for- 
ceps will prevent trouble far more frequently than they will 
do harm. 

After the occurrence of the hemorrhage but little can be done, 
medically or surgically. 



CHAPTEE XXIII. 

Diseases of the Skin. 

Owing to the very delicate structure of the skin in child- 
hood many skin diseases at that period are different from those 
seen in adults. At this age the skin is much more susceptible 
to effects of irritants, and a number of lesions may result from 
mechanical causes, heat or cold, light, or medication, etc. 

INTEKTRIGO. 

This is a very common condition, and is a chafing or rubbing 
off of the superficial skin, which has been previously macerated. 
Its most frequent site is the buttocks, in folds between the but- 
tocks in the groins, and the scrotum. The chief cause is the 
practice of drying the napkins several times before washing 
them, or neglect in removal of fecal discharges. 

The primary lesion is an erythema, with deep congestion of 
the skin. Maceration takes place, and the superficial layer of 
epidermis is rubbed off. This leaves a moist, red surface, which, 
if an infection takes place, becomes inflamed, covered with pus 
and encrustations. 

Treatment. Prophylaxis is most important. Intertrigo is 
generally an indication of carelessness on the part of the nurse. 
Xapkins should be properly cared for, boiled daily, without 
strong alkaline washing powders. Soap should not be used 
on the skin of the buttocks frequently. A soft cloth and warm 
water should be used after evacuations, followed by a drying 
powder. 

"When the first symptoms develop all digestive disturbances 
should be corrected, that the discharges may be as unirritating 
as possible and the urine examined for hyperacidity. The nap- 

567 



568 THE DISEASES OF CHILDREN 

kin should be changed immediately it is wet or soiled, both 
day and night. 

Stearate of zinc powder applied to the affected area as soon 
as cleansed and dried will frequently correct the condition 
promptly. If much thickening and congestion of the skin is 
present, Lassar's paste will be found efficient. 

SUDAMIWA. 

This eruption is characterized by minute papules, which are 
surmounted by transparent vesicles, due to the collection of 
sweat drops under the epidermis. Some erythema is seen 
between the patches. 

Associated with this rash is usually considerable itching, the 
child scratching even in its sleep. 

The eruption is general, but chiefly located on the chest, 
neck and back. 

The vesicles rupture leaving a roughened surface, followed by 
a fine, scaly or branny desquamation. 

Treatment. Cool sponging, followed by drying with a soft 
cloth and free use of talcum powder, gives comfort and relief 
from the itching and assists in drying up of the vesicles. 

Parasitic Skin Lesions, 
pediculosis. 

This is an infection of the hair of the body with animal 
parasites, affecting the hair of the head, the body, or the hair 
of the pubes. 

PEDICULOSIS CAPITIS. 

This form is due to the invasion of the hair of the head by 
the parasite pediculus capitis. 

The headlouse is grayish in color, about 3 mm. in length, oval 
in shape, with six legs, containing claws arising from the 
anterior portion. One female is capable of laying about 50 
eggs, which hatch in about a week. The eggs or nits are at- 



DISEASES OF THE SKIN 569 

tached to the side of the hair one-fourth to one-half an inch from 
the scalp, nsiially two or three to a hair, and can be easily seen 
by the naked eye. The occipital and temporal regions are more 
thickly contaminated than the rest of the head. 

Pedicnli cause severe itching, resulting in scratching, with 
abrasions and infections of the skin, a variety of exudations 
forming on it. If many of these are present the postcervical 
and submaxillary glands may become enlarged from absorption 
of pus. With large encrustations and matting of the hair there 
is a very disagreeable odor to the head. 

Diagnosis. Examination of the head should always be made 
where great itching is present. The nits can be easily found, 
and usually a parasite, especially if a .fine tooth comb is run 
through the hair. A pustular encrustation on the scalp and 
neck is a suspicious occurrence. 

Treatment. Both the pediculi and the ova must be destroyed. 
If in a girl with long hair and the infection is very great, a cure 
will be much more rapid by cutting the hair or boxing it. In 
a boy this can be easily done. The use of the fine tooth comb 
is necessary. 

A number of remedies have been advocated, none, however, 
infallible. 

The head should be washed with green soap and the follow- 
ing applied: 

I^ Kerosene oil 

01. olivse aa 5iv 

M. Sig.: Applied to the hair and thoroughly rubbed in, the head tied up 
and allowed to remain over night. 

The hair is shampooed the next morning with green soap, 
and this treatment repeated each night for three nights. 

Tincture of coculus indicus, diluted one-third, can be applied 
in the same way; also bichloride of mercury, gr. i to the ounce 
of water. To soften and remove the ova a solution of bicarbon- 
ate of soda or of dilute acetic acid can be used to advantage. 



570 THE DISEASES OF CHILDREN 

PEDICULOSIS GORPOEIS. 

This is due to the pediculus corporis, a louse larger than the 
headlouse. It reproduces itself in the underclothing, the ova 
being deposited in the seams and folds, and hatching in about 
a week. 

The parasite fixes itself upon the skin and sucks blood there- 
from, this causing great itching. The scratching is severe, both 
day and night, which is evidenced by the excoriations on the 
body wherever the finger nails can reach. The site of severest 
itching is where the clothes fit the body closest, as the waist, 
shoulders, across the back, etc. An inspection of the body may 
not reveal the parasites, but they are found on the underclothes. 

This form of louse is rarely seen in infancy, and is uncom- 
mon in children of any age. It is found chiefly among the poor 
and uncleanly, but rarely among negroes. 

The diagnosis is chiefly to be made from scabies. 

The treatment cannot be successful without careful disinfec- 
tion of the clothing and daily change of the underclothes. 
Thorough soaking of the underclothes in a 1/20 carbolic acid 
solution, followed by boiling, is efficient to sterilize them. 

The itching can be relieved by the use over the body of a 
5 per cent carbolic acid ointment. 

PEDICULOSIS PUBIS. 

This is only seen after puberty, and is due to an infection of 
the pubic hair by the pediculus pubis, or crab-louse, and is, of 
course, not seen in children. 

Occasionally these parasites infect the eyebrows and eye- 
lashes. The parasites are smaller than the other forms of lice, 
and bury their heads in the hair follicles. The nits are depos- 
ited upon the hair and hatch in about the same time as the 
other varieties. 

The lice can be removed with forceps and the nits removed 
by vigorous rubbing and the application to the eyebrows of a 



DISEASES OF THE SKIN 571 

carbolic acid ointment, 5 per cent, or a 50 per cent mercurial 
ointment with vaseline. 

SCABIES OR ITCH. 

This is due to the invasion of the skin by the sarcoptes 
scabiei, and is characterized by burrows, in which the female 
lays her eggs, and intense itching. 

Symptoms. It is a comparatively frequent occurrence in 
children, and especially in institutions, newly admitted chil- 
dren bringing in the infection often. It is highly contagious. 

The female parasite burrows into the skin, these forming 
an irregular line about an eighth of an inch in length, elevated, 
grayish in color. 

The most frequent sites of the burrows are the back of the 
hands, between the fingers ; the wrists ; toes ; inner sides of the 
thighs ; the scrotum in males ; around the waist and axillary 
region. 

A variety of eruptions are found over the affected areas, 
papules, vesicles, pustules, and excoriations due to the 
scratching. 

Examined under a magnifying glass the acarus can be seen 
at one end of the burrow. 

The chief symptom is the itching, most severe at night, dis- 
turbing gTeatly the rest and sleep of the child. According 
to the amount of pruritus and the coincident scratching is the 
extent of the eruption. 

Wearing clothes formerly worn by an infected person, using 
the same towels, sleeping with one infected, or in an unchanged 
bed formerly occupied by an infected person, are the most fre- 
quent means of propagation. 

The female acarus is considerably larger than the male, easily 
seen with a magnifying glass. It is yellowish in color and 
ovoid in shape. The female perishes in the epidermis after 
depositing her ova in the burrow. 



572 THE DISEASES OF CHILDREN 

Diagnosis is not always easy, but is suspicious whenever a 
case presents with severe itching and the multiform eruption 
upon the body as described above. The finding of the burrows, 
not always easy, is the diagnostic sign. Pediculi affect the body 
almost exclusively. 

Eczema must be differentiated. Except as a complication of 
scabies, so extensive an eczema with an arrangement as in 
scabies is unlikely to occur. 

Treatment. The object of treatment is to destroy the acarus 
and relieve the resultant skin lesions. Sulphur, balsam of 
Peru and tar are the most efficient remedies. 

The child is given a hot bath with thorough soaping and vig- 
orous rub with rough towel afterward. The towel is boiled 
before again used. After this the whole body affected is anointed 
with an ointment containing sulphur, or sulphur and balsam of 
Peru, as follows: 



or 



I^ Sulphur precip. 
Balsam Peruv. 


gr. xl 
3i 


Adipis 
Vaseline 


aa Sss 


M. ft. ung. 




I^ Beta naphthol 
Balsam Peru 


gr.xxx 
3i 


or Sulphur precip. 
VaseUne 


gr. xl 
Si 


M. ft. ung. 





This method of treatment is repeated each of three succeed- 
ing nights, and at the end of this time precipitated sulphur is 
sprinkled between the sheets at bed time. Sheets and night 
clothes are changed each day. 



RINGWORM. 



Pingworm named, is according to the site affected, of the 
scalp, tinea tonsurans; of the body, tinea circinata; of the 
groin, tinea cruris. 



DISEASES OF THE SKIN 573 

Two spore fungi have been found as cause, of these condi- 
tions, the small spore, microsporon audouini, and the large 
spore, trichophyton. 

There are several varieties of each fungus. 

TINEA CIECINATA. 

Lesions due to the microsporon appear on any part of the 
body, often upon the backs of the hands. 

Symptoms. It begins as a small, scaly, papular patch, soon 
assuming a circular form, the outer ring generally being slightly 
elevated and scaly. As the ring enlarges the skin within be- 
comes shiny and tense and of a deeper color than the healthy 
skin. One or two, or many ringworm patches, may be found. 
It may occur with or without an involvement of the scalp. 

One source of infection is through the medium of domestic 
pets, cats or dogs. 

Pathology. A scraping from the scaly patch, treated with 
liquor potassse, 10 to 30 per cent solution, after 10 or 15 min- 
utes shows under the microscope a network of mycelial threads, 
bifurcated, with few^er spores. The latter are round, about 
1/800 of an inch in diameter. 

Treatment. Painting the patches with the tincture of iodine 
is usually sufficient to cure. This may be repeated once daily 
for two or three days. Any of the parasiticide drugs in the 
form of an ointment mav be used as follows : 



I^ Ung. sulphuris 


Si 


Ac. carbolici 


gr. X 


M. ft. ung. 




I^ Hydrargyri ammoniat. gr. xx 


i Ung. zinci oxidi 




Vaseline 


aa §ss 


M. ft. ung. 




I^ Beta naphthol 


gr.xx 


Resorcin 


gr.xii 


Ung. aquse rosae 


§i 


M. ft. ung. 





574 THE DISEASES OF CHILDEEN 

TINEA TONSURANS. 

Synonym. Ringworm of scalp. 

A disease of the scalp due to the tricophyton tonsurans^ char- 
acterized by a disease of the hair which causes them to fall out, 
leaving circumscribed areas of baldness, with scaly surface. 

Etiology. This disease is due to the tricophyton tonsurans, 
or the microsporon audouini. It affects children, in the main, 
and is directly transmitted from child to child, or through the 
medium of combs or brushes, towels, caps, bedding, etc. A 
cat, dog or rabbit may convey the organism. 

Pathology. An examination of a hair from the diseased 
area, or a scale from the epidermis, treated with the liquor 
potassse solution, the spores can be easily seen under the scale, 
and attached in numbers to the hair, and the mycelial threads 
running longitudinally. The hair is broken off leaving a rough 
end. 

Symptoms. The disease begins upon any portion of the 
scalp, being at first limited to the scalp, but later on affecting 
the hair and hair follicle. The period in which only the scalp 
is involved may be entirely overlooked as practically no symp- 
toms present. The first evidence may be a bald spot appearing 
upon some part of the scalp, the hair being broken off and the 
skin in the area, as a rule, scaly in appearance. These areas 
vary in size from a five-cent piece to the size of a silver dollar. 
On an attempt to pull out a hair in the diseased area the hair 
breaks close to the scalp. 

A differentiation is made by dermatologists of the lesion 
caused by the large and srhall spores. In the large-spored type, 
or the tricophyton or endothrix variety, the lesions are much 
smaller in size than the small-spored type. 

The course of the disease is slow and prolonged, as it may 
remain for years if treatment is not instituted. 

Diagnosis. The occurrence of circumscribed areas of bald- 
ness in one or more places in the scalp is characteristic of ring- 



DISEASES OP THE SKIN 575 

worm. An examination of tlie hair treated by liquor potassse 
under the microscope will clear up the diagnosis. 

It must be diagnosed from alopecia. This is usually more 
rapid in its course, and the scalp affected smooth and soft, the 
hair apparently normal, at least not brittle, and contains no 
spores. 

Prognosis. This is one of the most intractable of the skin 
lesions of childhood, and requires several months of active and 
persistent treatment before a cure can be obtained. 

Treatment. Careful segregation of ringworm subjects should 
be insisted upon, and they should be made to wear a skull cap 
made of muslin at all times so as to prevent the dissemination 
of scales and broken hairs containing the spores. 

The hair should be closely clipped from the whole head, or 
if a girl, and this is objected to, a small area around the af- 
fected spot should be closely cut. The diseased area is vigor- 
ously rubbed with green soap, or its tincture, and with a nail 
brush thoroughly scrubbed each morning, followed by the appli- 
cation of the medicament decided upon, for the purpose of de- 
stroying the spores. This can be done only by producing an 
inflammatory reaction in the skin of the affected area. The fol- 
lowing have been recommended as effective for this purpose: 

I^ Sodium chloridi ^ 

Vaseline aa 5ss 

M. ft. ung. 
I^ Sulphur precipitat. 

Beta naphthol aa 3i 



Balsam Peruv. 


5ss 


Vaselini 


§i 


M. 




IJ Hydrargyri bichloridi 


gr.i 


Kerosene oil 




01. oHvae aa 


5ss 


Alcoholis q. s. 


Biv 


M. 




I^ Ol.Tiglii 


5i 


Sulphur precipitat. 


5ii 


Vaseline 


51 


M. ft. ung. 





576 THE DISEASES OF CHILDREN 

Any one of these applications is to be used once daily, until 
an inflammatory reaction is obtained, when it is discontinued 
for a few days, and a simple ointment, as a 3 per cent boracic 
acid ointment applied until the reaction disappears, when the 
original ointment is again applied. 

For the intractable cases the X-rays have been recommended, 
with 10 to 15 minutes' exposure, static current and high vacuum 
tube are suggested as most beneficial. 

TINEA FAVOSA. 

Synonym. Favus. 

Etiology. This is a disease due to a mould fungus, Achorion 
schoenleinii, and is contagious. It usually begins in childhood, 
and most frequently among the poor, especially in foreigners, 
Poles, Russians and Jews. The domestic pets may cause its 
dissemination. 

Pathology. The epidermis, hair and hair follicles are in- 
volved. The crusts which form in favus are much thicker than 
in ringworm, it is cup-shaped, the scutulum, yellowish in color, 
and made up of mycelia and spores. The area beneath a scu- 
tulum is red and moist. 

Symptoms. The scalp is more often affected, and also areas 
of the body, and either may be affected alone. The occurrence 
of the favus cup or scutulum, the size of a split pea, the con- 
cave side up, usually with a hair in its center, is the first diag- 
nostic sign, and when dislodged leaves a moist, often bleeding 
area, slightly depressed, beneath. If the inflammation is exten- 
sive, the cups may coalesce. The hair looks dead, but is not as 
brittle as the hair in ringworm. Itching is usually present. 
Healed areas on the scalp show slightly depressed bald scars. 

Diagnosis is to be made from eczema and ringworm. It may 
be diflicult to make a diagnosis from ringworm of the body if 
the characteristic lesion is not present in the scalp also. The 
scutula do not appear in any of the other diseases mentioned. 

Prognosis. This is very unfavorable, as a cure is with diffi- 
culty obtained. 



niSEASES OF THE SKIN 577 

Treatment. The liair in the affected area must he pulled 
out first, however, removing the scutula. Applications of a 
strong solution of bicarbonate of soda will accomplish this. The 
scalp can be soaked with oil and the crusts scraped off. Epila- 
tion can proceed when the affected area is clean, and is a very 
tedious process, as each hair must be carefully pulled out sep- 
arately. Bulkley recommends the following stick for epilation : 

I^ CerseflavsR 3ii 

Laccae in tabulas 3iv 

Picis burgundicae 3x 

Gummi damar § iss 

M. Moulded into stick. 

The end of the stick is melted and when warm applied to the 
hair and twisted off" when cold. 

Any of the applications recommended for tenia tonsurans 
can be used to advantage in this. 

In addition, the following can be used : 

I^ Chrysarobin gr. xv to xx 

Vaseline ~ § i 

M. 

I^ Hydrargyri oleat. gr. x 

Vaseline §i 

M. 

I^ Pyrogallol 5 per cent. 

I^ Acetic acid sprayed on the scalp in an atomizer. 

The X-rays may be used in intractable cases the same as in 
ringworm of the scalp. 

IMPETIGO CONTAGIOSA. 

Etiology. Due to the invasion of the skin by the pus organ- 
isms, and it is common among the children of the poor. It is 
not infrequently epidemic in institutions, when it once obtains 
a start. Scratching in pruritus, scabies and pediculosis may 
cause it. 



578 THE DISEASES OF CHILDREN 

Pathology. The staphylococcus aureus is believed to be most 
regularly present, though Eox has described the finding of the 
streptococcus also. 

Symptoms. The initial lesion is a vesicle, which quickly 
changes to a pustule, varying from the size of a pin head to a 
five-cent piece. The pustules rupture, their contents forming 
in a scab or crust. These can be removed, usually being at- 
tached to the hair, and leave a moist, bleeding area beneath. 
The pustules and the encrustations may coalesce, forming one 
large crust over the affected area. They are very superficial 
and leave no scars. 

The parts affected are chiefly the exposed parts of the body, 
and others may soon become affected by autoinoculation. The 
glands nearby may become enlarged. 

Diagnosis. The very superficial character of the vesicles, 
pustules and crusts, and the evident inoculation of other parts, 
is evidence enough for the diagnosis. It is to be diagnosed from 
pustular eczema, pemphigus and varicella, and should be easy. 

Treatment. The first indication is to remove the crusts. 'No 
medication will be of avail through these. Any oily substance 
will soften them, and they can be washed off with warm water. 
Bicarbonate of soda solution is helpful for this also. One of 
the following is then applied: 



I^ Ichthyol ammon. 

Vaseline 
M. 


sulph. 


3iss 
5i 


IJ Ung. hydrargyri ammon. chlor 

Vaseline 
M. 


■ gr.v 
5i 


I^ Hydrargyn chloridi mitis 

Vaseline 
M. 


gr. V 
Bi 


I^ Resorcin 

Ung. aquae rosse 




gr.x 
Si 


I^ Acidboracic 
Vaseline 




gr. XX. 



M» Sig.: Useful in the later stages. 



DISEASES OF THE SKIN 579 

PEMPHIGUS VULGAEIS ACUTA. 

This is a rather rare condition in children. Dubring reports 
16 cases in 16,863 cases of skin disease. It is characterized 
by the development of bullae or blebs, with more or less consti- 
tutional symptoms. 

Other varieties of pemphiguSj even more rare, are described, 
viz., pemphigus vegetans and pemphigus foliaceus. 

Etiology, l^othing is known definitely of the causation of 
this disease. There may be a connection between the nervous 
system and its occurrence. 

Pathology. The blebs may involve all of the layers of the 
skin, or only the epidermis. The contents of the blisters is a 
straw-colored fluid, containing leucocytes, and an infiltration of 
the entire skin. There may be an infection of the bullae and 
absorption of toxic products. 

Symptoms. Usually there are systemic symptoms preceding 
the development of the blebs, malaise, rigors or a chill, with a 
moderate rise of temperature. Slight pain or a stinging sensa- 
tion may be felt at the site of the developing bleb or bulla, a 
macular spot may develop, followed at once by the blister upon 
it. The blisters vary from the size of a split pea to an area 
2 or 3 inches square. They have no areola. The bullae develop 
in successive crops for six or seven days, as a rule. The skin 
of all parts of the body is affected, rarely the mucous mem- 
branes. In one of the two cases reported, the blebs formed 
upon the conjunctiva. Cohen has described one case of this 
kind occurring in 50,000 eye cases. The duration of an attack 
is three or four weeks, or it may last months. 

When this disease develops in the new-born, or shortly after 
birth, it is designated pemphigus neonatorum. 

Diagnosis is from varicella, dermatitis herpetiformis, impetigo 
and erythema multiforme. 

The latter is much more acute, the lesions more limited, 
and there is an erythematous base. 



580 THE DISEASES OF CHILDREN 

Prognosis. These cases may result fatally, especially if they 
run a chronic course, when the system becomes much depleted. 
Hemorrhagic extravasation in the bullse is an unfavorable 
occurrence. 

Treatment. The bullse should be punctured, under aseptic 
precautions, and the loose skin removed. Mild antiseptic ap- 
plications should be made to the raw surface below ; 5 per cent 
boracic acid ointment or 10 per cent ichthyol ointment. If 
the process is very extensive, the continuous bath treatment for 
several hours at a time is efficacious. 

Internally, arsenic is of curative value. Fowler's solution 
in increasing doses, to the point of tolerance, is indicated. 
Quinine is also of benefit, in 2 to 5 grain doses, and iron in the 
stage of convalescence. ISTourishing food is also of value, and 
the diet should be closely watched. 

The following cases occurred in my service at a local insti- 
tution, and it is through the courtesy of Dr. I. ]N^. Bloom, derma- 
tologist, that they are reported: 

Boy, nine years old, in the institution four months. When 
three years old had a number of boils requiring incision. Vac- 
cinated four weeks before with mild infection of site, but this 
had entirely healed 10 days previously, and the scab was off. 
Admitted to the infirmary with a temperature of 101.6° F., 
with a severe chill after admission. The following morning 
there was a hyperemic blush on the left arm, extending from the 
point of vaccination to the tip of the shoulder. There was 
pain at this point during the night. At the upper border of 
this area there was a large bulla 2 by 4 inches in dimensions, 
which contained about 2 drachms of transparent fluid. His 
tongue coated a dirty white and breath foul. By the next day 
a general bullous eruption had developed, Y2 bullse being 
counted. All parts of the body were affected, but the chest 
and abdomen. The surface beneath the bullse was red and 
moist, having the appearance of a scald. 

The mucous membrane of the mouth was involved in the same 



DISEASES OF THE SKIN 



581 



process. The left arm became involved almost over its entire 
extent, the palm of the hand on this side also being involved. 
It was very painful before the development of the bnllse there. 
Epistaxis occurred on the fourth and fifth days. On the 
fifth day blebs developed on the left conjunctivse, with pain 
and photophobia. The scalp was involved on the seventh day 
by a number of bullse. 




FIG. 61. PEMPHIGUS VUDGARIS ACUTA. 

The temperature was fluctuating, rising before the develop- 
ment of each new crop of buUse. 

Recovery occurred in three weeks. 

Girl, eight years old, rather poorly nourished, in Home seven 
weeks. Invasion marked by a chill. Temperature chart ac- 
companies report. Elevation of temperature with each new crop 
of blebs. The largest bleb noticed was the result of coalescence 



582 



THE DISEASES OF CHILDKEN 



of several, 3x3 inches, and held about 3 ounces of fluid. Blebs 
appeared without erythematous base, first on belly wall, and 
soon after on legs. The belly wall, genitals, legs, thighs, wrists 
and dorsal surfaces of hands were most affected. The upper 
arms and forearms were comparatively free. Scattered blebs 
on scalp, face, back, buttocks and palms of hands and soles of 



OATE f ^^ ^ ^ J- (a T t 9 fo ffV^\f:b\N\fJ\-a\nVfV^V'''\ 


MCMEMEMEMEMJEMEMEM^EM 


EMEMEMEMEMEMEM'EMEt^E 






105 ■ — 


1 ^. . ^Q5 










104 


^ 104 




-A 


■ 03 i B ft lU-U- 


J ,03 


— I ' 114^ A f 1 \i W 


If 


,„,|iE5|pE:|;iEE4E:E 


1 . /M U 


— xij:- — 1 — ^ — \ n. . _j — i — 4- — 


E-EEEEEE-=FEE|E^zEi 


101 IV i ~l l\ 


1 ^+- fl ■ "101 


\ ^ 1 / \ ll 


U 1 k \U 1 


^ d - ^ ± ^ - 


dE:|=|-5:|g:===::,^ 


-\ — r--r 


||E^i5^Ei:^iiEEE:;; 


99 1 M 1 1 


^1 1^ T n r y 14199 


__i^ . _. 


\ ^_i| s_ 


1 \ \ ^ 

98 — 


===i==========^-i^'« 




1 1 M — 


9,-BMH^HS 


. . 97 



FIG. 62. PEMPHIGUS 



feet. One bleb developed on hard palate. The base beneath the 
blebs was red and moist and did not bleed. Appetite was good, 
bowels regular. Was apathetic except when lesions were dressed. 

The disease lasted 23 days, with a slight relapse four weeks 
later. 

Fowler's solution was given internally, tub baths for tempera- 
ture; removal of raised epidermis over the blisters, and raw 
surfaces covered with gauze spread with 5 per cent boracic acid 
vaseline ointment, this dressing confined by a bandage. 



DISEASES OF THE SKIN 583 

ECZEMA. 

This is one of the most important of the skin lesions of child- 
hood, not only because of its prevalence but because of the 
variety of its manifestations and clinical types. Fully one- 
third of all skin cases are eczema. 

Etiology. Much discussion has been indulged in as to the 
causes of this disease, with the subject still unsettled. Bateman 
says of this disease : ''Eczema is a non-contagious eruption gen- 
erally the effect of an irritant, whether externally or internally 
applied, but occasionally produced by a great variety of irri- 
tants in persons whose skin is constitutionally very irritable." 
The constitutional causes are most important, of which disorders 
of the digestive system are most frequent. Chronic constipa- 
tion, catarrhal conditions of the gastrointestinal tract, toxemia 
from acute indigestion or intestinal putrefaction. Rheumatic 
diathesis and anemia are also given as causes. Heredity plays 
an important role. The part the nervous system plays in the 
etiology is not well known, but that there is a connection is 
generally recognized. Dentition may be associated with a dis- 
tinct outbreak of eczema. 

Among the chemical and local causes are mustard, rhus, iodi- 
form, certain kinds of soap, dyes, exposure to cold, irritating 
effect of rough clothing, improperly washed napkins, etc. 

Pathology. A few changes are common to practically all 
clinical types of eczema ; a dilatation of the blood vessels of the 
corium; an edema of the papillary layer; vesicles under the 
horny layer. Marked cellular infiltration occurs in the chronic 
form, and thickening of the skin. 

Symptoms. Clinically, certain changes are practically com- 
mon to the several varieties. There is an erythematous ap- 
pearance of the skin, with formation on this of minute vesicles. 
With this there is a sense of burning or itching. The pruritus 
is specially prominent. There is a tendency of the vesicles to 
rupture with the formation of a moist surface, or one which 



584 THE DISEASES OF CHILDREN 

is encrusted or scaly. The process is patchy in character and 
there is a tendency to frequent exacerbations and recurrences 
or relapses. 

Eczema may be acute, subacute or chronic, and occur at any 
age. It is very frequent in childhood. Bulkley states that in 
3000 cases of eczema 676 occurred under the age of five years, 
and 520 of these were under three years of age. 

It has a special predilection for the face, in many instances 
beginning upon the face. 

The follov^ing varieties of eczema may be recognized clinic- 
ally: Eczema erytJiematosum, papulosum, vesiculosum, pus- 
tulosum, squamosum. 

Eczem^a ErytJiematosum. Occurs most frequently on the face, 
neck, hands and buttocks. As the name implies the first symp- 
toms are erythematous spots which quickly coalesce. When 
about the eyes there is edema of both lids. The skin is thick- 
ened, and is hot and dry. Itching and burning is severe. Mois- 
ture may be present if there is much scratching. As the inflam- 
mation subsides the swelling decreases and the surface is cov- 
ered by small, branny scales. This form may become chronic. 

Eczema Papulosum. This affects the back, arms, hands and 
legs most frequently. There is an eruption of dull red papules 
the size of a pin head, discrete or formed in small groups. 
These groups may coalesce and cover larger areas. The pruri- 
tus in this form is much greater than the others, and as a result 
of the scratching the tops of the papules are scraped off, leaving 
bleeding spots which become inflamed from infection. Recur- 
rence of this form is frequent. 

Eczema Vesiculosum. This is the commonest form. The 
face, neck, hands and buttocks are oftenest affected. There are 
fine pin head size vesicles which develop on an erythematous 
base. Itching and burning precede the appearance of the ves- 
icles. These vesicles coalesce as the fluid in the skin forms, 
rupture, and the coagulation of the fluid forms a crust over the 



DISEASES OF THE SKIN 585 

surface, l^ew vesicles form at the margins, and the same 
process is repeated. 

The duration of the acute symptoms is about two weeks. If 
the crust is removed a moist, red base is uncovered. 

Eczema Pustulosum. If an infection of the vesicular form 
of eczema takes place, the pustular form will follow. The early 
signs are the same as in the vesicular type. The crusts are 
much thicker, and yellow or greenish in color. It is most often 
seen on the face and head. The early burning and itching may 
be present, but it is less marked after the pustules form. 

Eczema Squamosum may be a primary condition or any of 
the types' preceding may pass through the squamous or scaly 
stage before complete recovery. The skin is dry and covered 
with a fine scale. This is the seborrheic form, and occurs most 
often on the scalp of the child, often behind the ears and the 
eyebrows. When on the scalp it is the "milk crust" of the 
laity. A dirty yellow crust covers the scalp, and if it has been 
untreated sometimes is quite thick. 

Prognosis. Because of its proneness to recur, the prognosis 
as to a cure is not very favorable. The earlier treatment is 
begun the more chance for a prompt cure. Chronic cases 
respond slowly. 

Treatment. Attention to the general health of the child is 
indicated, its habits, food, bowels, kidneys, exercise, clothing, 
bathing, sleep, etc. Every detail of its life should be minutely 
ascertained as often a trivial cause will be found which is 
responsible for the condition. 

l^ot many internal remedies have been found of service. 
Arsenic is of doubtful value. Wine of antimony in 5 minim 
doses has been recommended. Turpentine in small doses has 
been recommended by Crocker. 

The child should not be allowed to scratch the inflamed area. 
This can be prevented by pinning the hands down to its dress, 
a rather unnatural method ; by tying them in small canton 
flannel bags, and by having the child wear a mask made of thin 



586 THE DISEASES OF CHILDREN 

muslin, with eyes, mouth and nose uncovered. Soap and water 
should be kept off the affected areas entirely. ISTo local remedy 
will be of avail if an attempt is made to apply it through the 
crusts. The crusts must be softened by the application of olive 
oil or soda solution and removed by a forceps. 

Among the indications present are application of soothing 
remedies in the acutely inflammed cases, when the vesicles form, 
applying astringent remedies. Locally, a large number of rem- 
edies have been suggested, evidence sufficient to decide that none 
is efficient in all cases. Lotions, ointments and powders are the 
forms in which remedies are applied externally. 

In the acute form of eczema with burning and itching, any 
bland application is of benefit as lead and opium wash ; biborate 
of soda solution, 3i to Oi, sopped or poured on several times a 
day. In the vesicular form, dusting powders are helpful; tal- 
cum, starch, magnesium carbonate, stearate of zinc, etc. Las- 
sar's paste is of benefit as a bland and unirritating application : 



I^ Tinct. picis liquidae 


Bi 


Acidi phenici 




gr.xl 


Glycerine 




5iss 


Zinci oxidi 




3ii 


Ext. hamamelis dest. 


5i. 




q. s. ad 


5vi 


M. 




(Schamberg.) 


I^ Zinci oxidi 






Amyli 




5ii 


Vaseline 




5ss 


M. ft. paste. 






I^ Zinci oxidi 




5ss 


Pulv. calamine 


prep. 


5iv. 


Glycerine 




gi 


Aq. calcis 




Bviii 


M. 




(Startin.) 



In the chronic form several drugs are of value, viz., tar, 
resorcin, salicylic acid, gelatin, chrysarobin, sulphur, ichthyol, 
silver nitrate, diachylon ointment, oil of cade, etc., and can 
be combined in many formulse. 



DlSiJASiJS OF THE SKIN 587 



HEEPES. 



Synonyms. Fever blister. Gold sore. 

Definition. A collection of vesicles upon the skin upon a 
common reddened base. They may occur upon the face, herpes 
facialis; upon the lips, herpes labialisj upon the genitals, her- 
pes genitalis; upon the body, herpes zoster. 

Symptoms. This eruption may occur independently or in con- 
nection with various febrile disorders, as pneumonia, tonsillitis, 
acute ^ 'colds," cerebrospinal meningitis, etc. 

The first symptom is a sense of burning and swelling, fol- 
lowed by a reddened base, and shortly by the crop of small 
vesicles, pin head in size or larger. The vesicles may rupture 
and form crusts. Successive crops may develop for several days, 
and there is a tendency for them to recur. 

Diagnosis. From eczema, impetigo. The latter, with great 
rarity, occur in single patches. 

Treatment. Ko special treatment is required. The diges- 
tion must be watched, the diet regulated and the bowels put in 
good condition. In recurrent cases, arsenic is of value. Locally, 
when the first symptom is noticed, the application of camphor 
or tincture of myrrh is of service; as soon as the vesicles have 
ruptured, dry calomel applied will be of service, or an ointment 
of calomel and vaseline, gr. x to Ji, or 5 per cent boracic acid 
ointment. 



HERPES ZOSTER. 



Synonym. Shingles. 

Definition. An acute inflammatory condition of the skin 
characterized by the formation of vesicles, distributed along 
the course of the cutaneous nerves, and accompanied by neu- 
ralgic pains. A comparatively rare condition in young children. 

Etiology. Season plays a part in etiology, it occurring more 
frequently in winter and spring. Exposure to cold is also a 
cause. There seems to be an intimate relationship between 



588 THE DISEASES OF CHILDREN 

the lesion in the skin and the changes in the nerve trunk, pos- 
sibly an interstitial neuritis of the peripheral nerves. 

Symptoms. After a brief period in v^hich sharp, burning 
neuralgic pains are felt over the region affected, successive 
crops of vesicles appear, following the course of the nerve 
involved. Papules and macules precede the vesicular stage a 
very short time. As a rule but one side is affected at a time. 
The most frequent parts affected are the areas supplied by the 
intercostal and trifacial nerves. Some fever may attend the 
formation of the vesicles. 

Diagnosis. Any vesicular eruption occurring upon one side 
of the body and following fairly accurately the course of a 
peripheral nerve is difficult to mistake for any other disease. 

Treatment. Protection of the eruption from injury or infec- 
tion is the first indication. It may be painted with tincture of 
benzoin, or an ichthyol collodion dressing, 3i to §i, or an 
ichthyol ointment can be used. 

Internally sedatives may be necessary for the pain, heroin 
or codeine. 

Quinine and arsenic are useful through the course of the 
disease. 

PRURITUS. 

In this condition there is no special pathology except that 
produced by the irritation due to scratching. Itching, however, 
is a prominent symptom of a number of the skin diseases of 
children; urticaria, scabies, eczema, sudamina, pediculosis, etc. 
It also occurs at the anus, pruritus ani, as a result of intestinal 
worms. 

An itching of the skin is evidenced by restlessness in the 
very young, disturbed sleep, and rubbing with hands and feet. 
The itching is usually intensified when the child is undressed, 
the air striking the skin causing it to become intensified. As a 
result of the scratching the skin may become infected and an 
impetigo result. Much infiltration of the skin results from 
long-continued scratching. 



DISEASES OF THE SKIN 589 

An -uiiderlyiiig general or systemic condition may be the 
cause of the condition acting through the nervous system, espe- 
cially the cutaneous nerves. 

Treatment. If possible, the diagnosis must be made giving 
appropriate treatment to the cause found. Internally, tonics 
and nerve sedatives are of value ; locally, the antipruritic rem- 
edies afford temporary relief. Bathing in a strong solution of 
bicarbonate of soda, or a solution of starch, allowed to dry on 
the skin, and ointments containing any of the following, or a 
combination of them, will prove effective; camphor, menthol, 
chloral, acid carbolic, liquor potassse, thymol, etc. 

URTICARIA. , 

Synonyms. Nettle rash, hives, lichen urticatus. 

A number of varieties may occur, urticaria factitia, urticaria 
papulosa (lichen urticatus), urticaria tuherosa, urticaria hemor- 
rhagica, urticaria bullosa. 

Etiology. This is generally considered as a cutaneous man- 
ifestation of a gastrointestinal disorder, and a resulting tox- 
emia, and either food or drugs may cause the same conditions. 
One family under my observation is peculiarly susceptible 
to quinine, it producing a general urticaria in four members; 
one cannot eat ripe fruit, berries or peaches without a severe 
case of urticaria, etc. The antitoxic sera, before their purifi- 
cation and elimination of the globulins from them, frequently 
caused both a local and general urticarial rash. 

Pathology. The process is most likely an angioneurosis. 
The process, as outlined, may be papular, vesicular bullous in 
character. 

Symptoms. The eruption appears suddenly and without 
warning, the most common variety appearing as raised papules 
or wheals of various sizes, with whitish tops and a red base. 
These are accompanied by a sense of burning and severe itching. 
They may be localized or the whole body may be affected. In 



590 THE DISEASES OF CHILDREN 

the urticaria factitia, letters can be traced on the skin, and they 
will stand out in bold relief in a few minutes. 

Demographism has been given to this phenomenon. 

The form in which large wheals appear is nsuallj of short 
duration, the fine papular form may last a number of weeks. 

Prognosis. The chronic form of urticaria is very unprom- 
ising, and fortunately is comparatively rare in children. The 
acute form is quickly recovered from, but has a tendency to 
recur. 

Treatment. In the acute cases, a brisk purgative is of benefit, 
and careful regulation of the diet will assist in the cure and 
prevent a recurrence. Inquiry as to special articles of diet 
should be made, in an effort to trace the direct cause of dis- 
agreement. Milk of magnesia is a good remedy to correct the 
acidity as well as for its laxative effect. 

Locally, the application of a hot bicarbonate of soda solution 
or a general bath containing the soda, is of benefit. The fol- 
lowing lotion is recommended by Schamberg: 



I^ Menthol. 


gr.xxx 


Acidi phenici 


f5i 


Tinct. picis mineralis 


Si-ii 


Ext. hamamelis dest. 


oi 


Zinci oxidi 


3ii 


Glycerini 


3ii 


Spt. vini rect. 


Bii 


Aquae camphorse 


5ii 


Aquae dest. q. s. ad 


Bviii 


M. 





APPEJSTDIX. 

Milk Modifications. 

Mathematical equations are the basis of the majority of 
methods for the modification of milk, and one of these should 
be selected by the physician, memorized and used. 

The following are some of the most practical which have 
been suggested. 

The method devised by Baner is probably the most useful 
and practical; it is as follows: Determine the quantity to be 
fed in 24 hours and the percentage of the ingredients, and use 
the following formula: 

Q = quantity in 24 hours; C ^= cream in ounces. (In the 
following equation if a 20 per cent cream is used, 16 will be 
the divisor; if a 16 per cent cream is used, 12 will be the 
divisor; and if a 12 per cent cream is used, 8 will be the 
divisor. ) M = whole milk in ounces ; E = percentage of fat 
in the mixture; P = the proteids, and L (lactose) = dry sugar 
of milk in ounces : 

C = — (if 12 per cent cream is used.) 

Q y, P — c 

M = (i. e., the proteids in cow's milk.) 

W = Q-{C + M). 

{L.~P)XQ ^ ._ . . 

L. = — — (result bemg m ounces). 

Let 20 ounces be the quantity to be fed in 24 hours (10 
feedings of 2 ounces each) and the formula be: Fat, 2 per 

591 



592 APPENDIX 

cent; sugar, 6 per cent; proteids, 1 per cent; the equation will 
be as follows: 

20 X (2 - 1) 20 
C =g =2ioz. 

20 XI 

M = 2i = 5 - 2A = 2i oz. 

4 

PT = 20 - (2i + 2^) = 20 - 5 = 15 oz. 

100 100 100 ~ ^^* 

Ordinary gravity cream contains 16 per cent of butter fat, 
and if 2 parts of this are added to 1 part of milk (containing 
4 per cent fat), 12 per cent cream will be obtained. 

Westcott has also devised mathematical formulae for cal- 
culating milk mixtures as follows : 

C = cream in ounces ; M = whole milk in ounces ; ¥ = fat ; 
P = proteids ; L = lactose, sugar of milk, dry in ounces ; Q = 
total quantity ; S = sugar percentage : 

(F-P)Q 

8.2 (12 p. c. cream) or 12.4 (16 p. c. cream) or 16.8 (20 p. c. cream) 



C = 



QF 
M = -^- 3 C (12 p. c.) or 4 C (16 p. c.) or 5 C (20 p. c.) 

^ ^ QS - 4.S iM+ C). 
100 

If a 20 ounce mixture is desired, containing 3 per cent of 
fat, 6 per cent of sugar, and 2 per cent of proteids, using 16 
per cent cream, the formula would read : 

(3 - 2) 20 20 

C = = = 1.6 oz. 

12.4 12.4 

20 X 3 

M = — ^^(4 X 1.6) =f- 15 - 6.4 =8.6 oz. 

20X6-4.3(8.6+1.6) 12 0-43.86 ^ ^^ „ 

L = ^ = = 0.76 oz. I oz. 

100 100 



APPENDIX 593 

Conversely, in order to determine the percentage of ingredi- 
ents in any combination of cream, milk and sugar, Westcott 
suggests the following: 

To find the percentage of fat: 

C 

— X 16 (or 12) = fat percentage from cream. 

M 

— X 4 = fat percentage from milk. 

Sum of these = fat percentage in mixture. 
To find the percentage of proteids: 

(J 

— X 3.6 (16 p. c.) or 3.8 (12 p. c.) = proteid percentage from cream. 
Ji. 

M 

— X 4 = proteid percentage from milk. 

Sum of these = proteid percentage in mixture. 

100L + 4.3(MC) 

Sugar percentage = 

An illustration : Take the above mixture, 1-J ounces of 16 
per cent cream, 8.6 ounces of milk, f ounce of lactose, and 19 J 
ounces of water: 

1.6 

X 16 = 1 .28 per cent fat from cream. - 

20 

8.6 

X 4 =1.72 per cent fat from milk. 

20 

1.28 -{- 1.72 = 3.0 total per cent fat in mixture. 

1.6 

X 3.6 = 0.28 proteid per cent from cream. 

20 F F 

8.6 

X 4 =1.72 proteid per cent from milk. 

20 f f 

0.28 + 1 .72 = 2.00 total proteids in mixture. 

100X0.76 + 4.3X10.2 76 + 3.9 

= = 6 per cent sugar. 

20 20 ^ 



594 



APPENDIX 



Westcott had also devised a scale on cardboard discs which 
show the amount of each ingredient to use.. 

Hamilton's method is based on the fact that cream, milk 
and skimmed milk contain relatively the same amount of 
proteids and salts: 

Multiply quantity of the mixture by the percentage of fat 
desired and divide by the percentage of cream used, the quo- 
tient equals the amount of cream. 




FIG. 63. westcott's milk modification chakt. 



Multiply the quantity of milk mixture by the percentage of 
proteids desired, and divide by 4, the percentage of proteids in 
skimmed milk; subtract from this the amount of cream to be 
used, the result equals the amount of skimmed milk. 

The quantity of cream and skimmed milk subtracted from 
the total quantity gives the amount of diluent. Three drachms 
of lactose must be added to each 10 ounces of the mixture. 

Example. Forty ounces of mixture desired, of the following 
formula: Fat, 4; sugar, 7; proteids, 2; 16 per cent cream. 



APPENDIX 



595 



40 X 4-^-16 = 10 ounces of 16 per cent creani. 

40 X 2 -f- 4 — 20 — 10 = 10 ounces of skimmed milk. 

40 — 20 = 20 oimces of diluent. 

Sugar = 4 level tablespoonfuls. 

Lime water, q. s. 

CONlSrOs's TABLES. 

The following is Connor's table for milk modification: 



ooi 






























PER CENT FAT. 








Ii 


§1 


gS^ 


















« 

S Pi 


23 C3 


£§2 


















fe Ck 


0, 


1 




1^ 1 


_j-, 


^ 


^ 


^ 


*j 


+3 




g* 






3. 


a 


c 


c 


c 


c 


a 






3 


s ' 


8-7 





8-7 


«^ 


§0 


a; 

^^ 


II 

'ii 


s 


^ 


^• 


1c' 


13 


ai 


H 

'it 


11 


M 

(M S 


i% 

'- m 


cog 

ii 

GO 03 




a 




15 




la 


OS 


02 


= ' 

'"''*) 


or 








"§ 


S 


§^ 





as 


§•- 











^5^ 


ss 


f^ Pu 


CQ 





H 


H 


H 


Eh 


H 


H 




fe 


1 7 


0.13 


0.50 


0.75 


1.00 


1.25 


1.50 


1.75 


2.00 


0.41 


0.50 




6 


0.14 


0.57 


0.86 


1.14 


1.43 


1.71 


2.00 


2.30 


0.46 


0.57 




5 


0.17 


0.67 


1.00 


1.33 


1.67 


2.00 


2.34 


2.67 


0.54 


0.67 




4 


0.20 


0.80 


1.20 


1.60 


2.00 


2.40 


2.80 


3.20 


0.65 


0.80 




3 


0.25 


1.00 


1.50 


2.00 


2.50 


3.00 


3.50 


4.00 


0.81 


1.00 




2 


0.33 


1.33 


2.00 


2.67 


3.33 


4.00 


4.66 


5.33 


1.08 


1.33 


2 


3 


0.40 


1.60 


2.40 


3.20 


4.00 


4.80 


5.60 


6.40 


1.30 


1.60 


1 


1 


0.50 


2.00 


3.00 


4.00 


5.00 


6.00 


7.00 


8.00 


1.63 


2.00 


5 


3 


0.62 


2.50 


3.75 


5.00 


6.25 


7.50 


8.75 


10.00 


2.03 


2.50 


2 1 


0.67 


2.67 


4.00 


5.33 


6.67 


8.00 


9.33 


10.67 


2.16 


2.67 


3 1 


0.75 


3.00 


4.50 


6.00 


7.50 


9.00 


10.50 


12.00 


2.44 


3.00 



MILK MODIFIEKS. 



Several modifiers of milk have been introduced, the Haas' 
Materna, the Doming Modifier and Sloane Maternity Milk Set. 

The Materna is a 16 oimce glass graduate with pouring tip. 
The outer surface is divided into seven panels. One of these 



596 



APPENDIX 



shows the ounce graduation, the other six show as many 
formulae, so arranged as to be suitable for the entire first year's 
feeding. Having determined on the formula desired, the 
respective ingredients are poured into the graduate to the line 
designated for the substance then inserted. First, the milk 
sugar is put in, then warm water or whatever diluent is deter- 
mined upon, in which this is dissolved, the lime water, the 
cream and then the milk; the ingredients are then thoroughly 








^itim\NG PERCfWrA 

I - PAT£NT£» 

\ CtREQ CO UPPAf^ 



FIG. 64. DEMING MILK MODIFIER 



stirred, and resultant mixture should analyze the same as the 
formula at the top of the panel used, 16 per cent or gravity 
cream and whole milk are used in the mixture. Enough bottles 
for the 24 hours are filled to the required amount, stopped with 
absorbent cotton, kept on ice, and each bottle warmed to blood 
heat when used. The following are the markings on the panels 
of the Materna: 



APPENDIX 



597 



1 


2 


3 


4 


5 6 


Fat, 2% 
Proteids, 0.6% 


Fat, 21% 
Proteids, 1% 
Sugar. 6% 
1 MILK 


Fat, 3% 

Proteids, 1% 

Sugar, 6% 

MILK 


Fat, 3^% 

Proteids, 1^% 

Sugar, 7% 

MILK 


Fat, 4% Fat, 3i% 
Proteids, 2% Proteids, 24% 


Cream 


Cream 


Cream 


Cream 






1 

' 




Lime-water 






Lime-water 


Lime-water 










Water 


1 




Lime-water 




Water 


Water 


Cream 






Milk-sugar 






Milk-sugar 






Water 


Lime-water 


Cream 




Water 




Milk-sugar 




Barley gruel 




Milk-sugar 




Gr. sugar 


Milk-sugar 




















X 


V 


Y 


X 


X 

_ 




i 













The Deming percentage milk modifier is a 16 ounce grad- 
uate, its graduations and percentages being based on whole 
and top milks containing 3.2 per cent proteids and 4 per cent, 
T per cent, 10 per cent and 12 per cent fat: 



598 



APPENDIX 





GRADUATIONS AND MARKINGS. 




OUNCES. 


PEOTEIDS. 

Top line. 


■ FAT. 


16 

14 




Use 
4 p.c. milk or 
whole milk. 


Use 

7 p.c. milk or 

the top 16 oz. 

from one 

qiiart. 


Use 

10 p.c. milk or 

the top 11 oz. 

from one 

quart. 


Use 

12 p.c. milk or 

the top 9 oz. 

from one 

quart. 






per cent 


per cent. 


per cent. 


per cent. 


per cent. 


12 


2.4 


3.0 


5.2 


7.5 


9.0 




2.2 


2.7 


4.8 


6.8 


8.2 


10 


2.0 


2.5 


4.4 


6.2 


7.5 




1.8 


2.2 


3.9 


5.6 


6.7 


8 


1.6 


2.0 


3.5 


5.0 


6.0 




1.4 


1.7 


3.0 


4.3 


5.2 


6 


1.2 


1.5 


2.6 


3.7 


4.5 




1.0 


1.2 


2.2 


3.1 


3.7 


4 


.80 


1.0 


1.7 


2.5 


3.0 




.60 


.75 


1.3 


1.8 


2.2 


2 


.40 


.50 


.88 


1.3 


1.5 


1 


.20 


.25 


.44 


.62 


.75 



Directions. Look in the column headed proteids for desired 
percentage of proteids. Then move to the right until the 
desired percentage of fat is found in line with the percentage 
of proteids. Now look at the head of this fat column to find 
what strength of milk to use. Pour this milk into the modifier 
up to the desired percentage of proteids and add gruel or water 
to ^^top line.'' This will make 16 ounces. 

The percentage of sugar in the mixture will be almost exactly 
the same as the percentage of proteids : 

1 level tablespoonful of granulated sugar adds 2i%. 

2 level tablespoonfuls of granulated sugar add 5 %. 
l-J level tablespoonfuls of milk sugar add 2J%. 

3 level tablespoonfuls of milk sugar add 5 %. 
Slide a knife over the bowl of the spoon to make it level full. 
Example. To make a mixture 3 per cent fat, 6 per cent 

sugar and 1 per cent proteids, look in the proteid column for 
1 per cent. At the right of this will be found 3.1- per cent in 
the third column of fat percentages, which is headed: ''Use 



APPENDIX. 



599 



10 per cent milk or the tup 11 ozs from 1 qc." Obtain 1 quart 
of good, fresh milk, and when the cream shows plainly dip oil' 
the top 11 ounces into n pitclier or bowl, and stir to mix. The 
first dipperful will have to be removed with a teaspoon or the 
bottle will overflow when the dipper is inserted. Pour this 
milk into the modifier up to the 1 per cent proteids line. Then 
fill with gruel or water to ^'top line." Add 5 per cent sugar — 
2 level tablespoonfuls of gi-anulated sugar or 3 of milk sugar — 
and stir to dissolve tlie sugar. To add 5 per cent or 10 per cent 
of lime water to the mixture, leave out 1 ounce of gruel or water 
for 5 per cent or 2 ounces for 10 per cent, and replace Avith 
lime water. 

After the cream has risen on a quart of 4 per cent milk, there 
may be dipped from the top 7 ounces, 16 per cent fat ; 8 ounces, 
14 per cent; 9 ounces, 12 per cent; 10 ounces, 11 per cent; 11 




As the cream in the 
bottle is not uniform 
in richness, always 
remove full quantity 
of Top Milk called for 
and mix before using. 



l<^k<V-.^V^'V.V^ 



'' ^^^^^^ ] 



FIG, 65. TOP MILK. 



ounces, 10 per cent; 13 ounces, 9 per cent; 15 ounces, 8 per 
cent; 16 ounces, 7 per cent; 20 ounces, 6 per cent; 24 ounces, 



600 



APPENDIX. 



5 per cent; for 4 per cent milk or whole milk sliake the bottle 
to mix the cream and milk; to obtain fat-free milk dip off the 
cream and use the remaining milk. 

As the modifier is marked, 50 combinations of fat under 
4 per cent may be had with proteids below 2 per cent, and 36 
with proteids below 1 per cent. But by using the above-men- 
tioned milks 12 different percentages of fat may be had with 

When half graduations are used 



each percentage of proteids. 





FIG. 66. MILK DIPPER WITH ROUNDED BOTTOM. 



proteids may be varied by .10 per cent, and fat by .12 per cent, 
.15 per cent, .19 per cent, .22 per cent, .25 per cent, .31 per 
cent, .35 per cent, .38 per cent, .44 per cent or .50 per cent, at 
a time, giving over 200 hundred combinations of fats and 
proteids. 

The Sloane Modifier, Cragin's method, consists of a glass 
holding 20 oimces, and Chapin's Cream Dipper, holding 1 



APPENDIX. 601 

fluid uiiiice. Tlic folloAYiiig directions are give]i for the use 
of this moditier : 

From the upper part of a quart bottle which has stood four 
liours are obtained two kinds of top milk : 

Top Milk 'No. 1. Obtained bj taking 10 dipperfuls from 
the top of the bottle, the first dipper being filled with a spoon 
to prevent spilling, the remaining 9 dipperfuls being taken 
by dipping carefully from the bottle. These 10 dipperfuls are 
to be mixed in a clean pitcher, and from the milk thus mixed 
the baby's food may be prepared until it is from four to six 
months old. * 

Top Milk No. 2. Obtained by taking IG dipperfuls from the 
top of the bottle, the first dipper being filled as before wdth a 
spoon, the remaining 15 dipperfuls being taken by dipping 
carefully from the bottle. 

These 16 dipperfuls are to be mixed in a clean pitcher, and 
from the milk thus mixed the baby's food may be prepared 
from the age of about four months until it is a year old. 

In using this milk set, wdi a tevei\ strength of food is desired, 
the sugar and the lime water are always the same: 1 ounce of 
milk sugar (or i ounce of granulated sugar) and 1 ounce (1 
dipperfull of lime w^ater. 

The quantity of food made by filling the glass once is ahvays 
the same— 20 ounces. The strength of the food varies with 
the number of dipperfuls of top milk used. 

Preparation of the Food. First, into the measuring glass pour 
milk sugar u]) to the line marked 1 ounce milk sugar, or gran- 
ulated sugar up to the line marked one-half ounce granulated 
sugar. 

Srroiid. Add 1 dipperful of lime w^ater and mix by shaking 
the glass. 

Third. Add the required number of dipperfuls of top milk, 
according to the age of the baby, as explained below\ 

Fourth. Fill the measuring glass np to the line marked 20 
ounces of food with water, either plain or barley w^ater or oat- 
meal w^ater. 



602 



APPENDIX 



MODIFICATION OF MILK LADD S TABLE 





TWENTY-OUNCE MIXT- 
URES, PERCENTAGE OF 


OUNCES OF CREAM 


OUNCES OF FAT-FREE 

MILK USED WITH 

CREAMS OF 


OUNCES 
OF 


3 

i 

a 

bl) 

3 

I 




NO. 


Fat. 


Sugar 


s 

o 

a; 


< 


10 

p.c. 


IS 
p.c. 


16 
p.c. 


20 
p.c. 


10 

p.c. 


12 
p.c. 


16 
p.c. 


20 
p.c. 


1 
i 


Is 

1 
'o 
P5 


72 


1 


1.50 


4.50 


0.25 


5 


* 


* 


* 


H 


* 


* 


* 





1 


174 


2 


0.33 


2 


1.50 


4.50 


0.50 


5 


3 


2i 


2 


U 





* 


1 


u 


1 


16 


2 


0.61 


3 


2.00 


5.00 


0.25 


5 


* 


* 


* 


2 


* 


* 


* 





1 17 


2\ 


0.75 


4 


2.00 


5.00 


0.50 


5 


* 


H 


2i 


2 


* 





4 


1 


1 


15f 


2\ 


0.73 


. 5 


2.00 


5.00 


0.75 


5 


4 


3i 


2^ 


2 


i 


U 


2\ 


2| ! 1 


144 


2 


1.01 


6 


2.00 


5.50 


1.00 


5 


4 


3i 


2i 


2 


n 


2i 


3i 


n 


1 13i 


2\ 


l.:-!0 


7 


2.50 


6.00 


0.50 


5 


* 


* 


31 


2i 


* 


* 





f 


1 I 151 


2\ 


O.T.i 


8 


2.55 


6.00 


0.75 


5 


* 


4i 


3i 


2h 


* 


\ 


li 


2 


1 


144 


2\ 


1.01 


9 


2.50 


6.00 


1.00 


5 


5 


4i 


3i 


2\ 


1 


n 


21 


3* 




134 


24 


1.23 


10 


3.00 


6.00 


0.50 


5 


* 


* 


3f 


3 


+ 


* 





f 




15i 


24 


0.84 


11 


3.00 


6.00 


0.75 


5 


* 


* 


3f 


3 


* 





U 


2 




14 


24 


1.12 


12 


3.00 


6.00 


1.00 


5 


6 


5 


3f 


3 





1 


2i 


3 




13 


2\ 


1.35 


13 


3.00 


6.00 


1.25 


5 


6 


5 


3f 


3 


u 


2\ 


3* 


4i 




llf 


2\ 


1.35 


14 


3.00 


6.50 


1.50 


5 


6 


5 


3i 


3 


2h 


3i 


41 


5% 




104 


2\ 


1.91 


15 


3.00 


6.50 


2.00 


5 


6 


5 


3f 


3 


5i 


6i 


71 


8% 




74 


2 


2.68 


16 


3.50 


6.00 


0.50 


5 


* 


* 


* 


3* 


* 


* 


* 







154 


24 


0.78 


17 


3.50 


6.00 


0.75 


5 


* 


* 


4i 


3i 


* 


* 





1 


1 


144 


24 


1.01 


18 


3.50 


6.50 


1.00 


5 


* 


51 


4i 


H 


* 





u 


2i 




13i 


24 


1.26 


19 


3.50 


6.50 


1.25 


5 


7 


51 


4i 


3^ 


h 


If 


3 


4 




114 


24 


1.68 


20 


3.50 


6.50 


1.50 


5 


7 


51 


4* 


3^ 


2 


3i 


4% 


5i 


1 


10 


2\ 


2.02 


21 


4.00 


6.00 


0.60 


5 


* 


* 


* 




* 


* 


* 







15 


24 


0.78 


22 


4.00 


6.00 


0.75 


5 


* 


* 


5 




* 


* 





1 




14 


24 


1.12 


23 


4.00 


7.00 


1.00 


5 


* 


* 


5 




* 


* 


1 


2 




13 


2f 


1.35 


24 


4.00 


7.00 


1.25 


5 


* 


61 


5 




* 


1 


2* 


3i 




114 


24 


1.68 


25 


4.00 


7.00 


1.50 


5 


8 


61 


5 




1 


2i 


4i 


5 




10 


24 


2.02 


26 


4.00 


7.00 


2.00 


5 


8 


61 


5 




3i 


4f 


6i 


74 


1 


74 


2\ 


2.56 


27 


4.00 


7.00 


2.50 


5 


8 


61 


5 




6i 


n 


n 


lOi 




4f 


2 


3.20 


28 


4.00 


7.00 


3.00 


5 


8 


6f 


5 




n 


10% 


12i 


13i 




If 


14 


3.88 


29 


4.00 


6.00 


3.00 


5 


8 


61 


5 




9i 


m 


12i 


13i 




If 


1 


3.88 


30 


4.00 


5.50 


3.00 


5 


8 


61 


5 




9i 


m 


12i 


13 i 


1 If 


f 


3.88 



* Combination impossible with percentages of cream indicated. 

For 25-ounce mixtures multiply the amount of each ingredient by 
For 30-ounce mixtures multiply the amoimt of each ingredient by 
For 35-ounce mixtures multiply the amount of each ingredient by 
For 40-ounce mixtures multiply the amount of each ingredient by 
For 45-ounce mixtures multiply the amount of each ingredient by 



APPENDIX 



603 



Age of infant. 



Interval 

in 

hours. 



No. of feed- 
ings in 
24 hours. 



No. of 

night 

feedings. 



A . Total 

Amount amount 

ounces at ounces in 

each feeaing. 34 hours. 



1 week . . . 

2 weeks . . 
4 weeks. . 
6 weeks. . 
8 weeks. . 

3 months. 

4 months. 

5 months . 

6 months. 

7 months. 

8 months. 

9 months . 

10 months. 

11 months. 

12 months. 



2 
2 
2 

2i 

2* 

2* 

2i 

3 

3 

3 

3 

3 

3 

3 

3 



10 
10 
9 
8 
8 
7 
7 
6 
6 
6 
6 
6 
5 
5 
5 



1 

2i 

3 

31 

4 

4+ 

5i 

5i 

6i 

7 

7 

8* 

8! 

9 



10 

15 

22^ 

24 

26 

28 

31i 

33 

341 

371 

42 

42 

42J 

43f 

45 



Formula on which the Average Healthy Baby may be started: 

Premature No. 1 or 2 

2-4 weeks No. 5, 8, 9, or 11 

1-2 months No. 12 or 13 

2-4 months No. 19 or 20 

4-6 months No. 24 or 25 

6-8 months No. 26 or 27 

8-9 months No. 28 

TABLE FOR ESTIMATION OF FAT PERCENTAGES IN CREAMS. 

One quart of whole milk, of 4 per cent fat, will yield on an average 
approximately: 

Cream 10 per cent in the upper 8 oz. after 6 hours. 

Cream 10 per cent in the upper 11 oz. after 8 to 12 hours. 

Cream 12 per cent in the upper 8 oz. after 8 hours. 

Cream 16 per cent in the upper 6 oz. after 8 hours. 

Cream .20 per cent in the upper 4 oz. after 4 to 6 hours. 



WHEY CREAM MIXTURES. 

Whey cream mixtures may be obtained by using whey as a dilutent, in place 
of the boiling water, preferably in the combinations containing low proteid per- 
centages. Each 2 ounces of whey replacing an equal quantity of water in a 
twenty-ounce mixture, will raise the whey proteid percentage 0.10, and will 
increase the sugar percentage 0.50. The total sugar percentage is, therefore, 
the amount contributed bv the cream and fat-free milk, which is indicated in 



604 APPENDIX 

the last column of the table on the reverse of the card, plus that of the whey. 
The amount of dry sugar which must be added to make the desired final sugar 
percentage can be easily calculated by reference to the following table: 

1 measure of dry lactose in a 20-oz. mixture gives 2.00 per cent of sugar. 

^ measure of dry lactose in a 20-oz. mixture gives 1.00 per cent of sugar. 

I measure of dry lactose in a 20-oz. mixture gives 0.50 per cent of sugar. 

(One measure is approximately one level tablespoonful.) 

Example — If in formula 21 fourteen ounces of whey are added in place of 
the same quantity of water, the whey proteids are increased 0.70 per cent, mak- 
ing total proteids of 1.30 per cent. The sugar contributed by the cream is 
0.78, by the whey 3.50, making a total of 4.28. The desired percentage of 
sugar is 6, therefore the balance of 1.72 per cent may be obtained by adding 
a little short of one measure of sugar. 

Whey should be made of fat-free milk, and should be heated to 150° F. (65° 
C.) before it is added to the cream mixture, to destroy the rennet enzyme. 
One quart of fat-free milk will yield about 24 ounces of whey. 

During the first montli it is usually better to use plain water, 
after that barley water, or if the baby is very constipated, oat- 
meal water. 

Streng-th of the Food for Different Months. Fi7^st Day. Give 
no milk; put in milk sugar to mark, then fill with boiled water. 

Second Day. Add 1 dipperful of top milk 'No. 1. 

Third Day. Add 2 dipperfuls of top milk No. 1. 

Fourth Day. Add 3 dipperfuls of top milk No. 1. 

Fifth to Tenth Day. Add 4 dipperfuls of top milk I^o. 1. 

Tenth to Thirtieth Day. Add 5 dipperfuls of top milk No. 1. 

One Month or Tiiw Months. Add 6 dipperfuls of top milk 
No. 1. 

Tiuo Months to Four Months. Add 7 dipperfuls of top milk 
Ko. 1. 

Four Months to Nine Months. Add 10 dipperfuls of top 
milk :Nro. 2. 

When the baby needs more than 20 ounces in the 24 hours, 
fill the measuring glass twice instead of once, before putting 
the food into the baby's bottle. 

After nine months the food is prepared by shaking the quart 
bottle of milk when first obtained and using the plain mixed 
milk. 



APPENDIX 605 



HALE S METHOD. 



Hale"^ suggests the following method of modifications : 
Rule 1. To find the percentage of fat (or sngar or proteid) 
in any mixture multiply the number of ounces used of each 
fat (or sugar or proteid) containing factor by the percentage 
of fat (or sugar or proteid) it contains, and divide the sum of 
fat (or sugar or proteid) results by the number of ounces in the 
whole mixture. 

Example. A mixture is made up of 



2 ounces of 10 per cent cream, 
10 ounces of whole milk, 
f ounce of lactose, 
8 ounces of water, 



20 ounces in all, and we apply the rule. 
Fat from cream, 2 ounces multiplied by 10 per cent equals. . . .20 parts of fat 
Fat from milk, 10 ounces multiplied by 4 per cent equals 40 parts of fat 

60 parts. The 
sum of fat re- 
sults. 
Sugar from cream, 2 ounces multiplied by 4.50 per cent 

equals 9 parts of sugar 

Sugar from milk, 10 ounces multiphed by 4.50 per cent 

equals 45 parts of sugar 

Sugar from lactose, . 66 ounce multiplied by 100 per cent 

equals 66 parts of sugar 

120 parts. The 
sum of sugar re- 
sults. 

Proteids from cream, 20 ounces multiplied by 3.50 per cent 

equals 7 parts of proteids 

Proteids from milk, 10 ounces multiplied by 3.50 per cent 

equals 35 parts of proteids 

42 parts. The sum 
of proteid re- 
sults. 

*Archives of Pediatrics, Mav, 1908. 



606 APPENDIX 

These sums divided by 20, the number of ounces in the 
mixture, will give the percentages desired, thus: 



20 



\ 60 per cent fat, 120 per cent sugar, 42 per cent proteids. 

3 per cent fat, 6 per cent sugar, 2 , 1 per cent Droteids. 



These percentages represent the amount of fat, sugar and 
proteids the mixture contains, and with this knowledge we can 
intelligently appreciate the strength and proportion of the 
ingredients, and are prepared to reduce to grams, and then 
estimate the caloric ^^alues.'^ 

This example is given to make Rule 1 more clear. The fol- 
lowing data is obtained from the mother: 

In each bottle she ])uts 

2 ounces of milk. 
1 ounce of cream. 
^ oun(;e of lime water, 
2 1 ounces of water. 
1 heaping teaspoonful of lactose, equal to i ounce, § 

6 ounces 

What she has told us so far means very little, and Ave must 
inquire further. This we do, discovering that the milk is 
skimmed milk, and that the cream is from the top 6 ounces of 
the bottle. Thus the milk used would run about .Y5 per cent 
fat, 41.50 per cent sugar, 3.50 per cent proteids, and the cream 
about 18 per cent fat, 4.50 per cent sugar, and 3.25 per cent 

* An ounce equals 29.5 grams. One gram of fat yields 9.3 calories. Pro- 
teids and sugar each yield 4.1 calories pei gram. 

§ A Chapin ounce dipj)er, even full of milk-sugar, varies in weight frow 245 
grains to 280 grains Troy, with simlpe moderate juggling to settle it. When 
sugar is loosened in its can, or carton, and dipped out, a heaping tablespoonful 
varies from 235 grains to 338 grains. The damper and more sticky the sugar 
the more will remain on the spoon, Mallinckrodt's and Merck's running heavier 
than Squibb's. A dipi)ed and then struck tablespoonful runs from 140 grains 
to 172 grains. Here more of the sticky sugar pushes off than of the dry, A 
dipped heaping teaspoDnful runs from 85 to 100 grains, averaging approxi- 
mately 1 to 5 ounces. A dipped and then struck teaspoonful holds from 39 to 
47 grains. 



APPENDIX 607 

proteids. Having learned these facts we proceed to apply 
Rule 1, first for fat, next for sugar, and last for the proteids. 
The totals then are divided by 

Milk — 2 oz. multiplied by 0.75 p. c. equals 1.50 parts of fat from the milk. 
Cream — 1 oz. multiplied by 18.00 p. c. equals 18.00 parts of fat from the cream. 



which gives us 19.50 parts of fat in all. 

Milk — 2 oz. multiplied by 4.50 p. c. equals 9.00 parts of sugar from the milk. 
Cream — 1 oz. multiplied by 4.50 p. c. equals 4.50 parts of sugar from the cream. 
Lactose — 0.20 oz. multiplied by 100.00 p. c. equals 20.00 parts of sugar from the lactose. 



which gives us 33.50 parts of sugar in all. 

Milk — 2 oz. multiplied by 3.50 p. c. equals 7 . 00 parts of proteids from the milk. 
Cream — 1 oz. multiplied by 3 . 25 p. c. equals 3 . 25 parts of proteids from the cream 



which gives us 10 . 25 parts of proteids in all. 

The totals then are divided by 

6) Fat, 19.50 parts. Sugar, 33.50 parts. Proteids, 10.25 parts. 

3 . 25 p. c. fat. 5 . 58 p. c. sugar. 1 . 70 p. c. proteids. 

Rule 2. To find the number of ounces of any factor (be it 
cream, milk, etc., or sugar) that must be used to obtain any 
desired percentage of fat (or sugar or proteids), multiply the 
number of ounces in the whole mixture by the percentage of fat 
(or sugar or proteids) desired, and divide the result by the 
percentage in w^hich the fat (or sugar or proteids) occurs. 

Example. We wish to make up a 30 ounce mixture, contain- 
ing 2.50 per cent fat, using whole milk and water. Thirty 
ounces multiplied by 2.50 per cent equals 75 ; this divided by 
4 per cent gives 18.75 ounces as the number needed to give 
the required amount of fat. 

By way of further example, we will make up a 30 ounce mix- 
ture, containing 2.50 per cent of fat, 6 per cent of sugar, and 
1.75 per cent of proteids. Here the problem is complicated 
by the fact that the fat and proteids must both be entirely 
derived from the milk. The first step is, therefore, to ascertain 
the relation which the fat and proteids bear to each other. To 
do this we divide the percentage of the proteids by the per- 



608 APPENDIX 

eentage of the fat; thus, 1.75 divided by 2.50 gives .7. Which 
means that the relation of proteids to fat is as 7 is to 10. 

We now endeavor to hnd v.hat portion of a bottle of milk 
has fat and proteids in this proportion, or approximately so. 
in looking back over the percentages of fat and proteids in 
dilferent portions of a bottle, our eyes light upon the upper 
25 ounces, which contain 5 per cent fat and o.50 per cent 
proteids, exactly the thing we want. Having now found a 
niilk with the fat and proteids in the proportions desired, we 
proceed at once to lind the number of ounces necessary to give 
the required percentage of either the fat or proteids. it makes 
no difference which is chosen to work with, the proportion re- 
mains undisturbed. AVe will choose to work it out for the 
proteids. Applying Rule 2, we multiply 30 ounces by 1.75, 
which gives 52.50; this divided by 3.50 per cent gives 15 
ounces as the number of ounces needed to supply both fat and 
proteids in the desired amounts. AVe notice that in this case 
the amount of milk happens to be half of the bulk prepared, con-, 
sequently the dilution is one-half, which proves our calculation 
and tells us further that the sugar supplied by the milk is one- 
half of 4.50 per cent; that is, 2.25 per cent, making it unnec- 
essary for us to work it out by Rule 1. There is, then, 2.25 
per cent of sugar supplied; 3.75 per cent must still be added 
to make up the required 6 per cent. AVe apply Rule 2 and 
multiply 30 ounces by 3.75 per cent, which gives 112.50, and 
this divided by 100 per cent (the percentage of sugar in lactose) 
gives 1.125 ounces as the amount of lactose that must be used. 
This amounts to simply finding what 3.75 per cent of 30 ounces 
is, as we realize that 3.75 per cent should be written .0375. 

The upper third contains three times as much fat as proteids ; 
that is, in the ordinary bottled milk it contains about 10 per 
cent fat and a shade less than 3.50 per cent proteids. The 
upper half contains twice as much fat as proteids ; that is, 7 
per cent fat and 3.50 per cent proteids. 

In the use of 10 per cent milk it is very simple, for to obtain 
a certain percentage of fat in the 20 ounce mixture it is only 



APPENDIX 609 

necessary to multiply the desired percentage by 2 to find the 
amount of milk needed. This is clear when we look at it a 
little more closely. One ounce in 20 is evidently in the same 
proportion as 5 in 100 ; that is, 5 per cent. This 1 ounce is 
only 1/10 fat, so the amount of fat it gives is 1/10 of 5 per 
cent, which is .50 per cent, or ^ per cent; that is, one-half the 
number of ounces used. For every 1 per cent of fat desired 
2 ounces of such a milk must be used in each 20 ounce mixture. 

The proteids are one-third fat; thus, 1 ounce of this 10 per 
cent milk yields scant .17 per cent proteids in a 20 ounce 
mixture. 

The sugar is a little less than half the fat, or about .23 per 
cent in the 20 ounce mixture. As lactose is 100 per cent sugar, 
each ounce added increases the- sugar just 5 per cent. 

In using the upper half of the ordinary bottled milk, the 
calculations may be done as follows : This milk contains 7 
per cent fat, 4.50 per cent sugar, and 3.50 per cent proteids; 
that is, the proteids are just half the fat, and the sugar is 
.64, or approximately two-thirds of the fat, and may be so con- 
sidered. We have seen that 1 in 20 is 5 per cent. One ounce 
of milk, 7 per cent fat, in a 20 ounce mixture gives to that 
mixture that part of 5 per cent which 7 per cent is of 100 per 
cent, namely, 1/14.3; 1/14.3 of 5 per cent is .35 per cent; 
therefore, each ounce gives .35 per cent of fat, which is con- 
sidered -J per cent. This enables us at a glance to tell how 
many ounces are needed to give any desired percentage, namely, 
three times as many ounces as per cent of fat wished. 

The proteids in the mixture would be in the same proportion 
as in the milk used, namely, half the fat. 

The sugar would also be in the same proportion as in the 
milk; that is, two-thirds as much as the fat. 

Example. We wish 3 per cent fat, and take 9 ounces from 
the upper half of a bottle. Applying Rule 1 as a test, the mix- 
ture is seen to contain 3.15 per cent fat, which is close enough. 
We will now, by way of a more complete example, take a 
formula and work it out. We wish in every 24 hours to give 



610 APPENDIX 

a baby 33 ounces of a mixture containing 2.50 per cent fat, 
7 per cent sugar, and 1.25 per cent proteids. In order to have 
a margin for waste and possible breaking of a nursing bottle, 
we will make up 40 ounces. This will require just twice what 
the 20 ounces do. To make up a 20 ounce mixture with 2.50 
per cent fat, we take as many ounces of the 7 per cent milk as 
three times the percentage of fat desired. This gives 7.50 
ounces as the number to be used. For 40 ounces twice as much 
is taken. 

The sugar is two-thirds of the fat; that is, 1.66 per cent of 
sugar is supplied by the milk. We desire 7 per cent, so there 
is lacking 5.44 per cent ; that is, 5 per cent, and approximately 
1/10 of 5 per cent more. One ounce of lactose gives the 5 
per cent, and 1 drachm more is near enough to the 1/10 desired. 
Thus, 1 ounce and 1 drachm will bring the sugar up to 7 per 
cent in the 20 ounce mixture, twice as much will be needed in 
the whole amount being mixed. 

The proteids, because of their proportion, must be one-half 
the fat; that is, 1.25 per cent (or exactly 1.30 per cent), the 
percentage wished. Tlie whole mixture will then be made as 
follows : 

15 ounces upper half of bottle. 
25 ounces water 
2^ ounces lactose. 

40 ounces. 
CAEE OF BABIES IN HOT WEATHER. 

The following is a brochure"^ issued by the Babies' Milk 
Fund Association of Louisville in 1908 on the Care of Babies 
in Hot AVeather, which was distributed among the poor and 
sent to every new mother whose confinement was reported to 
the city health office: 

* Compiled by Letchworth Smith, M.D. 



APPENDIX 611 



TO KEEP THE BABY WELL. 



1. Give it pure air day and nigiit. 

2. Give it no food but mother s in Ilk, or milk from the 
bottle, or food directed by a physician. 

3. A\Tienever it cries or is fretful, do not offer it food, but 
give it water. _ 

4. Be sure that it cjets enough sleep — two naps, at least, 
during the day. 

5. Do not put too much clothing on it. 

6. Bathe it every day in a tub. 

7. Don't handle it; let it alone. 

THE CARE OF BABIES I]N" HOT WEATHEK. 

Clothing. In the hot weather a thin gauze shirt, a thin mus- 
lin slip, and a diaper. On the hottest days, the slip and diaper 
are enough. 

Keep the baby as cool and comfortable as possible. 

As soon as a diaper is soiled it should he removed. Place 
it in a pail with a cover to keep the odors in and the flies out. 
Cover it with water and wash as soon as ]30ssible in hot water, 
to which a little soda has been added. The diaper should be 
well rinsed and thoroughly dried before being worn again. 

At least once a week all diapers should be thoroughly boiled. 

After every movement the parts soiled should be carefully 
cleansed at once. Babies often get sick from being left in soiled 
diapers. Kever think of putting on any kind of baby powder 
until the skin is clean and fairly dry. 

If the skin becomes chafed in any of the cracks or Avrinkles 
apply a little zinc oxide ointment. 

Bathing. The best time for the bath is just before a feeding 
— if possible, at the same time each day. 

The baby should be bathed every day in a tub. 

The wator should be slightly warmer than its o^m body. 

Use soap that will not irritate its skin. 

Do not bathe within an hour after eating. 



612 APPENDIX 

In very hot weather finish the bath with a little cooler water, 
and give three or four general spongings dnring the day with 
cool water containing a little salt. 

If the child suffers from "prickly heat," bathe the affected 
skin with vinegar and water. But remember that a roughened 
or inflamed skin may be the sign of an infectious disease that 
needs the care of a physician. 

Sleep. After the bath let the baby sleep for two hours. 

Such a mid-day nap should be insisted on until the child is a 
3^ear old, and is advisable until the age of four. 

Cover the child only with a light sheet when it is hot. 

Fresh Air. Fresh air is very necessary. 

Leave the windows wide open. Never put a child to sleep 
in a close d-up room. 

Keep it out of doors as much as possible. 

Avoid the sun on hot days. Keep on the shady side of the 
street, or in shady spots in the park, or in any shady spots 
where the air is fresh. 

Bed. A baby's bed should be fiat, firm, clean and dry. 

Feather pillows are bad things for babies to lie on, especially 
in the summer. 

Feeding". Every mother should nurse her baby, if she can 
possibly do so. 

]^o other food is so good for a baby as mother's milk. 

Of the babies that die before they get to be a year old, nine 
out of every ten are bottle fed. 

Wash the nipple with cold water before and after each 
nursing. 

The mother should eat plain, well-cooked food and should 
see to it that her bowels move at least once each day. Constipa- 
tion in the mother is bad for both mother and child. 

She should be careful as to diet and habits of life. Beer and 
tea are harmful, and in large quantities (two pints or more 
daily) may be very injurious. 

Regular Feeding^. Begularity in feeding is one of the most 



APPENDIX 613 

important things in the care of a baby. Irregularity in feeding 
leads to over-feeding in most cases, and often causes sickness, 
diarrhea and death. 

Feed the child at regular intervals. 

Do not nurse it every time it cries. A child is not always 
hungry when it cries, but it will eat at almost any time that 
food is offered. If it eats before its stomach is ready for a 
fresh supply of food, it may become sick. 

The baby's stomach should be given a certain length of time 
to digest the food that is put into it. It should then have a little 
rest before it is called on to digest more food. If it is not 
allowed to rest, but kept at work constantly, it will become 
exhausted, and that means that the baby will be sick. 

If a baby cries between feedings give it a driiik of water that 
has been boiled and then cooled, with nothing in it. 

Even very young nursing babies should have water in hot 
weather between feedings. This can be given out of a spoon 
or a perfectly clean nursing bottle. 

Breast Feeding. From the Third Day to the Sixth Week. The 
baby should be nursed every two hours during the day, 6, 8, 
10, 12, 2, 4, 6, 8, and should be nursed only twice between 10 
p. m. and 6 a. m., not more than 10 feedings during the 24 
hours. The baby should not he allowed to nurse more than' 20 
minutes at a time. ISTursing longer than this may give the 
stomach more than it can properly digest before time for the 
next nursing. 

From the Sixth Weelc to the Third Month. During the day six 
nursings, two and one-half hours apart, at 6, 8.30, 11, 1.30, 4 
and 6.30. From that time on till morning only two nursings 
should be allowed. 

From the Third to the Sixth Month. The nursings should 
be three hours apart during the day, at 6, 9, 12, 3, 6, 10, with 
one only between that hour and 6 o'clock the next morning. 

From the Sixth to the Ninth Month. The times of feeding re- 
main the same but the night feeding shoidd he discontinued. 



614 APPENDIX 

The child may wake up in the night, but should be given a 
drink of cooled, boiled water. After a short time, if it is well, 
it will sleep through the night. 

From the Ninth to the Twelfth Month. I^ursings three and 
one-half hours apart. Five in number. IsTone at night. 

Bottle Feeding". If it^is absolutely impossible for a mother 
to nurse her baby, it may be possible to find a wet-nurse. If 
this cannot be done, it will be necessary to put the baby on the 
milk of some animal. 

Cow's milk should not be given to young babies much under 
a year old unless it is diluted with certain amounts of clean 
water or barley water. 

The best niilh you can get is not too good for the baby. 

If you cannot atford to drink good milk yourself, you may 
be able to get along without it, but the baby needs milk and 
the cleanest milk that can be obtained. Cheap milk is not clean. 
It is usually keeping milk from getting dirty that makes it 
expensive. 

All babies should have milk that is clean enough to be 
certified. 

All other milk should be heated to boiling as soon as it is 
purchased. 

To keep milk sweet get it from the milkman whose wagons, 
cans and horses look clean. If you know where he keeps his 
cows, go and see if he keeps them clean. 

Get your milk in a bucket ivith a cover so that the flies and 
dust can be kept out of it. See that the pail is well washed, 
scalded and turned upside down when not in use. 

Always keep the milk covered. Always keep it cold. 

If you cannot get ice, keep it in cold running water, or if this 
is not possible, ^vrap a damp cloth about the pail and set it in 
a draft of air. 

Feeding After One Year of Age. Children should be weaned 
when 12 months old, unless the w^eather is very hot or a physi- 
cian orders otherwise. 



APPENDIX 615 

\Vea)i gradually. At first substitute one bottle for one nurs- 
ing. After a few days give two bottles a day, and so on. 

Bottle-fed children at this age will require more than milk, 
although this should still form the chief part of their food. 

During the second year most children are badly fed. 

Four meals a day should be given, selected from the fol- 
lowing : 

Soft-boiled eggs ; strained broths of beef, mutton and chicken, 
containing small pieces of stale or toasted bread ; stale bread or 
toast with milk; hominy (cooked six hours) with milk; oatmeal 
or rice (cooked three hours) with milk; commeal (cooked two 
hours) with milk; farina (cooked one hour) with milk. The 
milk should be boiled unless it is certified milk. Do not feed 
meat, vegetables, candy, popcorn, sugar, bananas or anything 
else unless told to do so by a physician. 

Summer Diarrhea. ^Mien the baby has loose, green passages, 
it means that the baby is sick and needs medical attention. The 
disease is mild at first and often shows no other sigiis of illness 
than the diarrhea. There may be no fever. Such a baby often 
becomes dangerously ill in a short time. 

The simplest cases of vomiting and diarrhea during the sum- 
mer should not be neglected. 

Stop the milk at once. 

Give two teaspoonfuls of castor oil and feed nothing but 
barley water until the child can be taken to a doctor. 

Do not give it any cordials or teas or ''diarrhea mixtures." 

Flies. Remember that flies are dirty, and often carry 
disease. 

Keep milk and other food covered or where flies cannot get 
at it. 

The fly that falls into the milk bucket may have just come 
from a priv}^ used by a person having typhoid fever, and if 
so the one drinking the milk may contract the disease. 

Keep the soiled diapers covered so that flio^ cannot walk 

over them and then o>o to the food used in the familv. 

~ 1/ 



616 APPENDIX 

Windows and doors should be screened, especially if there 
is a baby in the family. 

Give the Baby a Chance. Do not get it in the habit of being 
held by its mother or by other children. 

Most babies suffer because they are used to- amuse older 
people, and are forced to laugh or are tossed about and excited 
when they need to be resting quietly. 

Get it early into the habit of going to sleep without being 
rocked. It is much better for the baby to learn to go to sleep 
without this motion, and to have it do so will save much time 
for the mother and enable her to do many more important 
things in the way of keeping things clean, and of resting herself. 

Children often cry when put down to sleep. If they are left 
alone and not handled or talked to they will soon go to sleep. 

Crying is one of the ways in which babies develop their 
lungs — a certain amount of it is ''natural," and will do no 
harm if you don't get nervous about it. 

Try to get people to leave the baby alone. Think how tired 
and irritable you get yourself on a hot day, and shield the baby 
as much as possible from excitement and ''attention." 

"Some of these things may seem like extra work, but they 
keep the baby well, and it is fnr less trouble to keep a baby 
well than to take care of a sick baby." 

A Mother. 

Milk Modifications. 

age, oke to two weeks. 

Suggestive Table of Feedings.^ 

Remove the top 1) ounces from 1 quart of bottled milk into a 
pitcher or bowl. Of this milk in the pitcher or bowl use 4 
ounces with 14 ounces of water or dextrinized gruel and two 
level tablespoonfuls of sugar. (F. 2.7, S. 6., P. .7.) 

* Theory and Practice of Infant Feeding. Chapin. 



APPENDIX 617 

Divide into nine feedings of 2 ounces each in separate nurs- 
ing bottles, and feed every two hours during the day and 
twice at night. 

TWO TO FOUR WEEKS. 

Remove the top 9 ounces from 1 quart of bottled milk into 
a pitcher or bowl. Of this milk in the pitcher or bowl use 7 
ounces with 20 ounces of water or dextrinized gruel and 3 level 
tablespoonfuls of sugar. (F. 3., S. 7., P. .8.) 

Divide into nine feedings of 2 to 3 ounces each in separate 
nursing bottles, and feed every two hours during the day and 
twice at night. 

SECOND MONTH. 

Remove the top 11 ounces from 1 quart of bottled milk into 
a pitcher or bowl. Of this milk in the pitcher or bowl use the 
entire 11 ounces with 22 ounces of water or gruel and 4 level 
tablespoonfuls of sugar. (F. 3., S. 7., P. 1.) 

Divide into eight feedings of 3 to 4 ounces each in separate 
nursing bottles, and feed every fwo and one-half hours during 
the day and once at night. 

THIRD MONTH. 

Remove the top 16 ounces from 1 quart of bottled milk into 
a pitcher or bowl. Of this milk in the pitcher or bowl use 
14 ounces with 18 ounces of water or gruel and 4 level table- 
spoonfuls of sugar. (P. 3., S. 7., P. 1.4.) 

Divide into seven feedings of 4 to 5 ounces each in separate 
nursing bottles, and feed every two and one-half to three hours 
during the day and once at night. 

FOTJK TO SIX MONTHS. 

Remove the top 20 ounces from 1 quart of bottled milk into 
a pitcher or bowl. Of this top milk in the pitcher or bowl use 



618 APPENDIX 

the entire quantity with 16 ounces of water or gruel and 4 level 
tablespoonfuls of sugar. (F. 3., S. 7., P. 2.) 

Divide into six feedings of 5 to 6 ounces each in separate 
nursing bottles, and feed every three hours during the day 
and once at night. 

SEVEN" TO NINE MONTHS. 

Remove the top 24 ounces from each 2 quarts of bottled milk 
into a pitcher or bowl. Of this milk in the pitcher or bowl 
use 33 ounces with 15 ounces of water or gruel and 4 level 
tablespoonfuls of sugar. (F. 3.5, S. 7., P. 2.2.) 

Divide into six feedings of 7 to 8 ounces each in separate 
nursing bottles, and feed every three hours during the day. 

TEN TO TWELVE MONTHS. 

Remove the top 24 ounces from each of 2 quart bottles of milk 
into a pitcher or bowl. Of this milk in the pitcher or bowl 
use 40 ounces with 8 ounces of water or gruel and 4 level table- 
spoonfuls of sugar. (F. 4., S. 7., P. 2.6.) 

Divide into five feedings of 8 to 10 ounces each in separate 
nursing bottles, and feed every three and one-half hours. 

TWELVE TO FOURTEEN MONTHS. 

Whole milk, or, if not digested well, add one-fourth gruel. 
Amount in the bottle from 9 to 12 ounces. Chicken, mutton 
or beef broths, in same amount, may also be given. 

Suggestive Formula (holt). 

First Series of Formulae. Fat to proteids, 3:1. 

Primary Formulse. Ten per cent milk or fat 10 per cent, 
sugar 4.3 per cent, proteids 3.3 per cent. Obtained (1) as 
upper portion of bottled milk, or (2) equal parts milk and 
(16 per cent) cream. 



APPENDIX 



619 



DERIVED FORMULAS, GIVING QUANTITIES FOR TWENTY-OUNCE MIXTURES. 



Fat 


Sugar 


.Proteids 


per 


per 


1 per 


cent 


cent 


cent 



I Milk sugar, 1 oz. ] 

<| Lime-water, 1 oz. |^ with 2 oz. of 10% milk 

[ ^^'ater qs. to 20 oz, J 



1.00 5.50 i 0.33 



II 


" 20 " 


" 3oz. 


' 10% 


' = 


1.50 


5.50 


0.50 


III 


20 oz. 


" 4 oz. 


' 10% 


' = 


2.00 


6.00 1 


0.66 


IV 


20 oz. 


" 5oz. 


' 10% 


' = 


2.50 


6.00 


0.83 


V 


20 oz. 


" 6oz. 


' 10% 


' = 


3.00 


6.00 


1.00 


VI 


" 20 oz. 


" 7 oz. 


' 10% 


( 


3.50 


6.50 i 

i 


1.16 



Second Series of Formnlse. Fat to proteids, 2:1. 

Primary Formula. Seven per cent milk or fat 7 per cent, 
sugar 4:A0 per cent, proteids 3.50 per cent. Obtained (1) as 
upper portion of bottled milk, or (2) bv using three parts milk 
and one part (16 per cent) cream. 



DERIVED FORMULAS, GIVING QUANTITIES FOR TWENTY-OUNCE MIXTURES. 















Fat 


Sugar 


Pro- 
teids 










per 


per 


per 

cent 










cent 


cent 


I \ Milk sugar, 


1 oz. 1 
1 oz. \ 












<j Lime-water, 
1^ Water qs. to 


with 3 oz. 


of 7% milk = 


1.00 


5.50 


0.50 


20 oz.J 












II 


< 




20 oz. 


" 4 oz. 


" 7% " = 


1.40 


5.75 


0.70 


III 


' 


( 


20 oz. 


" 5oz. 


" 7% " = 


1.75 


6.00 


0.87 


IV 


i 


' 


20 oz. 


" 6oz. 


" 7% " = 


2.10 


6.00 


1.05 


V 


i 


' 


20 oz. 


" 7oz. 


" 7% " = 


2.50 


6.50 


1.25 


VI 


' 


' 


20 oz. 


" 8oz. 


" 7% " == 


2.80 


6.50 


1.40 


VII 


" 


11 


20 oz. 


" 9oz. 


" 7% " = 


3.15 


7.00 


1 .55 


VIII " " 


20 oz. 


" lOoz. 


" 7% " = 


3.50 


7.00 


1.75 


Milk sugar, 


i oz.] 












IX < Lime-water 


1 oz. 


" 12oz. 


" 7% " = 


4.00 


7.00 


2.00 


[Wa 


iter c 


{.s. to 20 oz.J 













620 



APPENDIX 



Third Series of Formulge. Fat to proteids, 8 : 7. 

Primary Formula. Plain milk: Fat 4 per cent, sugar 4.5 
per cent, proteids 3.5 per cent. (When using Jersey or Alder- 
ney milk add one-fourth water.) 

DERIVED FORMULAS, GIVING QUANTITIES FOR TWENTY-OUNCE MIXTURES. 





Fat 
per 
cent 


Sugar 
per 
cent 


Pro- 
teids 
per 
cent 


\ Milk sugar, 1 oz. 
I <j Lime-water, 1 oz. > 


with 5 oz. plain milk = 


1.00 


6.00 


0.87 


Water q.s. to 20 oz. J 


^ 








II " " 20 oz. 


" 6oz. " " = 


1.20 


6.50 


1.00 


Ill " " 20 oz. 


" 8oz. " " = 


1.60 


6.50 


1.40 


IV " " 20 oz. 


" 10 oz. " " = 


2.00 


7.00 


1.75 


fMilk sugar, ^ oz.] 
V <j Lime-water, 1 oz. [> 


" 12 oz. " « = 


2.40 


5.00 


2.10 


Water q.s. to 20 oz. J 










VI " " 20 oz. 


" 14 oz. " " - 


2.80 


5.50 


2.50 


VII " " 20 oz. 


" 16 oz. " " = 


3.20 


5.50 


2.80 



Kerley " suggests the following formulae by diluting the top 
16 ounces milk; this will analyze, fat, 7 per cent, sugar 3.2 per 
cent, proteids 3.2 per cent. 



FROM THE THIRD TO THE TENTH DAY. 
Ounces. 



Milk (top 16 oz.) 3 

Lime-water ^ 

Milk sugar 1 

Boiled water to make .... 16 



Approximate Percentage Equivalent. 

Fat. 1.3 

Sugar 6.6 

Total proteid 0.6 



Ten feedings in twenty-four hours; 1 to 1^ ounces at each feeding. 

FROM TENTH TO THE TWENTY-FIRST DAY. 
Milk (tOD 16 oz ) 6 Approximate Percentage Equivalent. 

Lime-water H Fat 1 . 75 

Milk sugar U Sugar 6.8 

Water to make 24 Total proteid 0.3 

Nine to ten feedings in twenty-four hours; 1^ ounces at each feeding. 



* Treatment of Diseases of Children. Kerley. 



APPENDIX 621 



FROM THE THIRD TO THE SIXTH WEEK. 

Ounces. 
Milk (top 16 OZ.) ..10 Approximate Percentage Equivalent. 

Lime-water 22^ Fat 2.2- 

Milk sugar 2 Sugar 7.0 

Water to make ,.32 Total proteid 1.0 

Eight to nine feedings in twenty-four hours; 2 to 3 ounces each feeding. 

FROM THE SIXTH WEEK TO THE THIRD MONTH. 
Milk (top 16 Oz) 12 Approximate Percentage Equivalent. 

Milk sugar 2 Fat 2.6 

Lime-water 3 Sugar 7.2 

Watertomake 32 Total proteid 1.2 

Seven to eight feedings in twenty-four hours; 2^ to 4 ounces at feeding. 

FROM THE THIRD TO THE FIFTH MONTH. 

After this age two bottles of milk are required, 16 ounces being taken from 
the top of each bottle and mixed. At this time a cereal jelly is usually added 
to the food. 

Milk (top 16 oz.) 18 ADproxlmate Percentage Equivalent. 

Milk sugar 2 Fat 3.15 

Lime-water 4 Sugar. 6.4 

Water to make 40 Total proteid 1.4 

Six feedings in twenty-four hours; 4 to 5 ounces at each feeding, 

FROM FIFTH TO THE SEVENTH MONTH. 
Milk (top 16 OZ.) 21 Approximate Percentage Equivalent. 

Milk sugar 2 Fat 3 .50 

Lime-water 5 Sugar 6.4 

Water to make 42 Total proteid 1.6 

Six feedings in twenty-four hours; 5 to 7 ounces at each feeding. 

FROM THE SEVENTH TO THE NINTH MONTH. 
Milk (top 16 oz ) 27 Approximate Percentage Equivalent. 

Milk sugar 2^ Fat 3.9 

Lime-water 6 Sugar . 7.0 

Water to make 48 Total proteid 1.8 

Five to six feedings in twenty-four hours; 7 to 9 ounces at each feeding. 

FROM THE NINTH TO THE TWELFTH MONTH. 
Milk (top 16 oz.) 35 Approximate Percentage Equivalent. 

Milk sugar 2^ Fat 4.3 

Lime-water 6 Sugar 6.5 

Water to make 56 Total proteid 2.0 



622 APPENDIX 

The following are formulse as used by the Babies' Milk Fund 
Association adapted milk laboratory: 

Per cent. Ounces. 

Fat 1 Whole milk 8 

Sugar 6 Lime-water 2 

Proteid 1 10 per cent sugar solution 11 

Water 11 

8 bottles; 4 ounces. 

Fat 2 Top 9 ounces milk 44^ 

Sugar 7 Bottom or skim milk 3 

Proteid 1 10 per cent sugar solution 17^ 

Water 3 

7 bottles; 4 ounces each. 

Fat 3 Top 12 ounces milk 6 

Sugar 6 Bottom or skim milk 4 

Proteid 1 10 per cent sugar solution 17 

Water 8 

7 bottles; 5 ounces each. 

Fat 3.5 Top 12 ounces milk 6 

Sugar 7 Bottom or skim milk 18 

Proteid 2 10 per cent sugar solution 13 

Water 3 

6 bottles; 7 ounces each. 

Fat 1.3 Top 16 ounces from quart 3 

Sugar 6.6 Lime-water ^ 

Proteid 0.6 Milk sugar 1 

Water q. s 16 

Fat 2.2 Top 16 ounces 10 

Sugar 7 Lime-water 2^ 

Proteid . 1 Milk sugar 2 

Water q. s 32 

Fat 2.6 Top 16 ounces 12 

Sugar. 7 Milk sugar 2 

Proteid 1 Lime-water 3 

Water q. s 32 

Fat 3.1 Top 16 ounces from two quarts ... 21 

Sugar 7 Milk sugar 2h 

Proteid 1.6 Lime-water 5 

Water q. s 42 



APPENDIX 



623 



Per cent 

Fat 3.93 

Sugar 7 

Proteid 1.8 

Fat 4.3 

Sugar , 7.3 

Proteid 2.0 



Oimces 
Top 16 ounces from two quarts . ... 27 

Lime-water 6 

Milk sugar 2| 

Water q. s 48 

Top 16 ounces from two quarts ... 35 

Milk sugar 3 

Lime-water 6 

Water q. s 56 



HESS REFEIGERATOE. 

Dr. Alfred Hess" of Xew York has suggested an inexpensive 
home-made refrigerator which, if it could be put into general 
use among the poor, would prevent many cases of milk poison- 
ing among children who are fed milk teeming with bacteria, 
because it has not been kept cold. 

The illustrations given l>elow show the construction of the 
box. 




FIG. 67. HOME MADE REFRIGERATOR. 

Fig. 67. Vertical Section of home-made milk refrigerator; S, sawdust, 
excelsior or other cheap non-conductor of heat; T, cylinder of tin or gal- 
vanized iron; C, can in which is placed the milk jar M, surrounded by broken 
ice, I; N, newspapers nailed to lid of case. 



* Journal American Medical Association, vol. li, no. 4. 



624 



APPENDIX 




HOME MADE REFRIGERATOR. 



Fig. 68. Horizontal section of home-made milk refrigerator; M, milk 
container; I, broken ice; C, can for holding ice; T, tin or galvanized iron 
cylinder to prevent sawdust, S, from falling into space when can is removed 
for purpose of emptying water. 



Medical Formulary 



ANEMIA AND ENLARGED SPLEEN IN RACHITIS. 

I^ Thyroid extract gr. ^ 

Sacch. carb. iron gr. iij 

M. Sig. At one dose; three daily. 



(KopHk.) 



ASCARIDi^S 

I^ Extract spigeliae, 
Extract sennae, 

Syr. simplicis. aa ^ss 

M. Sig. One tablespoonful night and morning, for child of 4 to 5 years. 

(Campbell.) 

BRONCHIAL ASTHMA 

I^ Syrup ipecacuanhse gtt. xviv 

Antipyrinse gr. xij 

Sodii bromidi gr. xxiv 
Syrupi rubi ida^i 5v 

Aqusi q.s. §ij 

M. Sig. One teaspoonful at 2-hour intervals for child of one year. 

(Kerley.) 



APrENDix 625 



BLEPHARITIS 



I^ Acidi salicylici gr. v 

Ung, hydrargyri oxidi flavi 3j 

Ung. aquae rosse 3iij 

M. Sig. Locally. 



SIMPLE BRONCHITIS 



I^ Tinct. opii camph. 3j 

Syr. ipecacuanhae Tijjxxxij 

Syr. tolutani 5ij 

M. Sig. Teaspoonful every three hours. (Koplik.) 



Sic 





CHOREA 








n 


Sodii arsenatis 
Acidi carbolici 
Aqua? destillatse 




gr. iss 

nj^iij 
3iiss 




M. 


ft. solution. 








'ive minims 


as an initial dose and 


repeat 


, as indicated. 










(Campbell.) 




COLIC 








i^ 


Potassii bromidi 
Chloralis hydratis 
Syrupi 




gr. xvj 
gr. viij 

§ss 






Aquae menthie pip. 


q. s. 


5ij 




M. 


Sig. 3j ^t a dose. 






(Starr.) 


I^ 


Potassii bromidi 

Chloral 

Syrupi 




gr. xvj 
gr. viij 

§ss 





Aquae menthae pip. q. s. ad ^u 
M. ft. solution. 
Sig. One teaspoonful, repeated if needed, every hour for three doses. 

(Boivard.) 
I^ Emulsi asaf oetidae f 5 ij 

Sig. One-half to one teaspoonful as required. 

(Campbell.) 

MUCOUS COLITIS 

I^ Tinct. nucis vomicae gtt. xc 

Quininae bisulphat. gr. Ix 

M. Div. et ft. capsulae No. xxx. 
Sig. One after meals for child of five years. 

(Kerley.) 



626 





APPENDIX 






CONSTIPATION 






1} Strychnine sulph. 


gr. t 




Ext. belladon., 






Aloin aa 


gr. 3/20 




M. ft. pil. No. XV. 






Sig. One pill t.i.d. 


(Oppenheim.) 




CHRONIC CONSTIPATION 






I^ Sodii phosphatis 


gr. XXX 




Syr. niannae 


giiss 




Aquae anisi 


5iij 




M. ft. solution. 




Sig. 


One tablespoonful three times a day for 


a child under one year. 
(Bovaird.) 




I^ Pulv. glycyrrhizse comp. 


3ssto 5j 




at a dose. 






I^ PodophylHn 


gr-ij 




Syr. rhei arom. 


5ij 




M. ft. solution. 






•^ig- 5j ^t dose. 


(Koplik.) 



SPASMODIC CROUP 

I^ Antipyrinae gr. ij 

Sodii bromidi gr. iv 

Syr. ipecacuanhae gtt. iij 

Syr. rhei gtt. xv 

Aquae q. s. 3j 

M. Sig. One dose — eight in 24 hours to child from 3 to 6 years. 

(Kerley.) 



STIMULATING ENEMA 



^ 



M. 



^ 



Whisky 


3j 


Caffeine 


gr.* 


Tinct. digitalis 


gtt. ij 


Sol. sodii chloride (0.6%) 


3j 


Sig. Given at temp, of 102° 


to 105°] 


ACUTE ECZEMA 




Pulv. calaminae preparat. 


5ij 


Zinci oxidi 


Sss 


Glycerinae 


5j 


Liquor calcis 


5ij 


Aquae rosae 


5viij 



(Koplik.) 



M. (Holt). 



^ 



M, 



^ 



M. 



I^ 



M. 



APPENDIX 




Ac. salicylici 
Zinci oxidat. 
Amylum 
Vaselin 




gr. XXX 

aa gj 

giss 


01. fagi 
Glycerin 
Ung. diachylon 
Balsam Peru 




5iiss 

5j 

oiss 
nj^xxx 


SEBORRHEIC 


ECZEMA 




.esorcin 

ngt. aquaj rosa3 




gr.x 
5j 



627 



(Koplik.) 



(Koplik.) 



(Holt.) 



ACUTE GASTRIC INDIGESTION 

I^ Bismuth subnitratis, 
Cerium oxalatis. 

Sodium bicarbonatis aa §ss 

M. et div. in cht. No. xij. 
Sig. One powder to be given with each feeding. 



(Bovaird). 



M. 



CHRONIC GASTRITIS 

I^ Liq. potass, arsenit. Ti^xxvj 

Sodii bicarbonat. gr. xxiv 

Aquae menth. pip. q. s. ad giij 
Sig. One teaspoonful in a little water, t.i.d. 



(Starr.) 



SIMPLE GASTRO-ENTERIC INFECTION 



I^ 



R 



M. 



Bismuth subnitratis 






3ij 


(or Bismuth salicylatis 






3J) 


Acaciae 






gr. XXX 


Tragacanth 






gr. XXX 


Aquae 


q. s. 


ad 


5iv 


■ two teaspoonfuls every 


three hours. 


INFLUENZA 








Caffeine citrat. 






gr- ij 


Phenacetin 






gr. V 


Sodii bicarbonat. 






gr.x 


ft. cht. No. X. 









Sig. To child of one year — eight doses in 24 hours. 



(Bovaird.) 



(Kerley.) 



628 



APPENDIX 



ACUTE ILEOCOLITIS 



I^ Bismuth subgallat. 
Mucil. acacise 
Aquae 

M. Sig. 3j-q.2h. 



s. ad 



5 jgr-xv 

3ij 

Sij 

(Oppenheim.) 



PERSISTENT INTESTINAL INDIGESTION 



I^ Pulveris rhei 


gr. iv 


Sodii bicarbonat. 


gr. viij 


Syr. rhei aromatici 


5ss 


Aquae 


q. s. ad 5j 



M. Sig. One teaspooiiful once or twice daily. 



(Kerley.) 



M. Sig. 



ACUTE INTESTINAL INDIGESTION 

I^ Bismuth subiiitratis, 

Mucil. acaciae aa 3ij 

Mist, cretse "^iv 

One teaspoonful every three hours. 



(Bovaird.) 



CHRONIC INTESTINAL INDIGESTION 

T^ Sodii hyposulphitis gr. x 

Sodii salicylatis SiJ 

Aquae menthae pip. o^v 

M. ft. sol. 
^^ig- 3j i^^ water four times a day. 



(Bovaird.) 



CATARRHAL JAUNDICE 





I^ Potass, acetatis, 






Potass, citratis, 






Potass, bicarbonatis, aa 


5ij 




Aquae q. s. ad 


3iv 




M. ft. sol. 




Sig. 


One teaspoonful iii water t.i.d. 





(Bovaird.) 



MALARIA (hypodermic USE.) 

Ji Quininae bimuriat. 



Sodii chloridi 
Aq. destil. 



gr. j 

3iiss 



M. 



(BacelH.) 



M. Sig. 



Siff. 



M. 





APPENDIX 
mal.\bia; after-treatment 




o: 


I^ 


Tinct. ferri mur. 
Strychnias sulphate 
Liq. potassii arsenit. 
Tinct. capsici 
Acid phosphor, dil. 




gr. ss 
5iss 
5 iij 
Sij 






Glycerine q. s. 


ad 


§viij 




M. 


Shake. 








Sig, 


. 3j t-i.d., diluted. 

MALARIA 








^ 


Acidi salicylatis 
Acidi boraci 

Pulv. amyli, 




gr. X 
gr. Ix 






Pulv. zinci oxidi 


aa 


Bj 




. Apply freely over affected par 


•ts. 




(Kerley.) 


^ 


Ac. carbolic. 
Ac. boraci 
Zinci oxidi 
Glycerini 
Alcoholis 




nj7xxx 

OJ 
3iss 

3ij 






Aquce q. s, 


,ad 


5vj 




M. 


ft. lotion. 








Sig. 


, Apply localh^ to skin. 

MUMPS 






(Campbell.) 


^ 


Ichthyolis, 










Plumbi iodidi 


aa 


gr. xlv 






Amnion, chloridi 




gr. XXX 






Adipis lame hydrosi 




5j 




M. 


ft. ung. 








Apply 


to swelling three times daily. 




(Campbell.) 




PEDICULI CAPITIS 








^ 


Acidi acetici 
Etheris sulphurici 
Tinct. delphinii, 




3ij 

Siij 






Sp. vini rectificati 


aa 


5iv 




>ig. Apply to scalp daily. 






(Kerley.) 




RACHITIS 








^ 


01. morrhuse 
Phosphori 




5fv 

gr- iij 




M. 


ft. sol. 








Sig 


. One teaspoonful daily. 






(Campbell.) 



630 



APPENDIX 



RHEUMATISM 

I^ Sodii salicylatis 5ij 

Elix. simplicis 5iss 

Aquae q. s. ad § iv 

M. ft. sol. 
Sig. One teaspoonf ul four times a day after meals in plain or Vichy water. 

(Kerley.) 



TONIC IN RHEUMATIC HEART DISEASE 

I^ Liq. arsenicalis nj^ij 

Tinct. nucis vomicae (B. P.) njjiij 
Syr. aurant. cort. njjxx 

Aq. chloroformi 5^i 

M. Sig. One dose to be given after meals to child of seven. (Poynton.) 



^ 



ACUTE RHINITIS 




Tinct une belladonnae 


gtt.x 


Pulveris camphorae 


gr. v 


Pulveris Doveri 


gr. iv 


Sacch. lactis 


q.s. 


ft. tablets No. xxx 





M. ft. tablets No. xxx 
Sig. One every two hours in water to child of six months 



(Kerley.) 



I^ Sulphuris sublim. 5iv-vj 

Balsam Peruviani 5i-ij 

Adipis benzoinat., 

Petrolati aa q. s. ad "^iv 

M. Sig. Apply after hot bath to surface of body. (Campbell.) 



ULCERATIVE STOMATITIS 

I^ Potass, chloratis 3iss 

Acidi muriatici dil. 5j 

Syrupi 5 ss 

Aquae q.s. 5iv. 

M. Sig. 5ss to 3i every two or three hours. 



(Bovaird). 



CONGENITAL SYPHILIS 



I^ Hydrarg. chloridi mitis 

Ferri carb. sacch. 
M. ft. pulv. 
Sig. Four a day. 



gr. * 
gr. iij 





APPENDIX 




n 


liydrargyri bichloridi 


gr. ss 




Tinct. niicis vomicae 


gtt. xc 




Extracti ferri pomati 


gr.x 




Quinae bi sulphat. 


33 


M. 


Div. et ft. caps. No. xxx. 




Sig. 


One after meals. 





031 



(Korlcy.) 



VESICAL SrAS.M 

-11 Tiiic'l . liyoscyanii '^ss 

Potassii citratis o.J 

.Vijua^ dcstillat. 5^j 

5ss ill water e\-e]y hour to child of two yeai's. 



(Holt.) 



VULVO-VAGINITIS 

It, Acidi borici 

Pulv. amyli, 

Pulv. zinci oxidi 
M. Sisr. Locallv. 



gr. XXIV 
aa § ss 



(Kerley.) 



WHOOPI.N'G-COUGH 



I^ Antipyrinse 
Sodii bromidi 
Syr. riibi idfei 
Aquce 



gr. xvuj 
gr. xxx 

q. s. ad oij 



M. Sig. Six do^es in 24 hours for child of 15 months. (Kerley.) 

I^ Plydrogeu peroxid ^'J 

Glyeerinutn 5ss 

Aquit q. s. ad 5iv 

M. Siu. One teaspoonfnl in water every two hoitrs. (Silver.) 



INDEX 



Abscess, alveolar, 232 

symptoms, 232 

treatment, 232 
peritonsillar, 153 

etiology, 153 

symptoms, 153 

treatment, 154 
retropharyngeal , 151 

symptoms, 154 

treatment, 154 
Abt, Isaac A , 311 

Acetone, odor in cyclic A'omiting, 247 
in urine, 249 

tests for, 448 
Acid, boracic,in care of the iii^jples, 72 
Adenoids, 157 

pathology, 157 

symptoms, 157 

treatment, 179 
Adenitis in scarlatina, 37() 
acute, 463 

definition, 463 

etiology, 463 

pathology, 463 

prognosis, 464 

symptoms, 463 

treatment, 464 
chronic, 464 

diagnosis, 465 

symptoms, 464 

treatment, 465 
Addison's disease, 465 

diagnosis, 465 

pathology, 465 

prognosis, 465 

symptoms, 465 

treatment, 466 
Adrenal glands, tuberculosis of, 466 
Albumen water, 130 
Albuminuria, 470 

causes, 470 

diagnosis, 470 

etiology, 470 

pathology, 470 

prognosis, 470 

symptoms, 470 

treatment, 471 
cycHc, 470 
functional, 470 
intermittent, 470 



Alcoholic beverages and breast milk, 

■ 81 
Alveolar abscess, 232 
Amygdahtis, acute lacunar, 149 
Anatomy of infants, 1 
Anemia, 44'), 447 
in endocarditis, [:V.\ 
in rachitis, 501 
infantum, 447 

definition, 447 

diagnosis, 449 

etiology, 447 

pathology, 448 

prognosis, 449 

symptoms, 448 

treatment, 449 
pernicious, 447 
primary, 447 
secondary, 447 
symptomatic, 447 
Angina in scarlatina, 375 
Ani, sphincter, dilation of, in asphyxia, 

13 
Animal broths, 130 
Ankylostoma duodenale, 281, 448 

description, 286 

diagnosis, 287 

prognosis, 288 

symptoms, 287 

svnonyms, 286 

treatment, 288 
Anodynes, 62 

Antibodies in antitoxin therapy, 413 
Antimony and ipecac tablets, 205 
Antipyretics, medicinal, 61 
Antitoxin, diphtheria, 404 

complications following, 412 
Anus, imperforate, in new-born, 1 1 
Aortic regurgitation, 436 

pathology, 436 

physical signs, 436 

sjnnptoms, 436 
stenosis, 437 

pathology, 437 

physical signs, 438 

prognosis, 438 

symptoms, 437 
Aphthae, Bednar's. ?n, 221 

etiology, 224 



633 



G3L 



INDEX 



Aplithse — Coil t inued 

pathology, 224 

symptoms, 224 
Aj)pendicitis, 289 

blood count in, 293 

definition, 289 

diagnosis, 293 

etiology, 289 

pathology, 290 

prognosis, 294 

treatment, 294 

in tyi)lioid fevei", 31 1 
catarrhal, 293 

symptoms, 291 
gangrenous, 290 

symptoms, 292 
sclerotic, 290 

symptoms, 293 
ulcerative, 290 

symptoms, 292 
Appendix, 591 
Aprosexia, 144, 158 
Arrowroot gruel, 131 
Artificial foods, 138 
Arthritis, 320 

diagnosis from rheumatism, 320 
septic or tubercular, 320 
in scarlatina, 376 
Ascaris lumbricoides, 281, 283 

description, 283 

diagnosis, 284 

symptoms, 284 

treatment, 284 
Ascites in mitral stenosis, 435 
Asphyxia, forms of, 10 

prognosis, 11 

symptoms, 11 

treatment, 11 
Astigmatism, mixed, 177 
Ataxia, hereditary, 540 

diagnosis, 541 

etiology, 540 

pathology, 540 

prognosis, 541 

symptoms, 541 

treatment, 541 
Atelectasis, 28, 192 

etiology, 192 

pathology, 192 

symptoms, 192 

treatment, 193 
following asphyxia, 11 
Athrepsia, 493 

diagnosis, 494 

etiology, 493 

pathology, 493 

prognosis, 494 



Athrepsia — Con tin ued 

symptoms, 494 

treatment, 494 
Auditory canal, diseases of exter- 
nal, 161 
Auscultation, 54 

Babcock, 105, 425, 426, 430, 431, 43!) 

milk tester, 118 
Habies. care of, in hot weathei-, (ilO 

]\lilk Fund Association of Louis- 
ville, Ky.. 117, 611, 622 

outfit, 18 
Babinski's reflex, 49, 508 
Bacillus coli communis, 237 

cyanogenes, 91 

hay, 237 

Klebs-Loeffler. 110 

lactis aerogenes, 237 

viscosus, 91 

Shiga, 237 

subtilis, 237 
Bacteria in milk, 91, 237 

lactic acid, in milk, 91 

of stomach and intestines, 237 
Bacterial count, method of, in milk, 

92 
Baeyer's test for acetone, 249 
Balanitis, 486 
etiology, 487 
symptoms, 487 
treatment, 487 
Baner's milk modification, 591 
Barley gruel, 129 
Barnhill, 173 

Basket, contents of baby's, 17 
Bassinet, 15 
Bath, 62 

bran, 64 

brine, 65 

mustard, 64 

soda, 64 

temperature, 16 

for temperature, 63 

thermometer, 62 

tub, 63 
Bathing of new-born, 16 
Bednar's aphthae, 224, 229 
Bed- wetting, 483 
Beef juice, 130 

scraped, 132 
Bell's palsy, 528 
Bermuda arrowroot, 131 
Bevan's operation for undescended 

testicle, 492 
Biceps jerk, 507 



IXDEX 



635 



Biedert, 126 

cream mixture, 125 
Bleeder, 460 
Blepharitis, 177 
etiology. 178 
symptoms, 178 
Blisters, 52 
Blood, 293 

count in appendicitis, 293 

corpuscles, red, 444 

diseases, 443 - 

general consideration of changes, 

446 
letting in nephritis. 478 
method of examination, 443 
picture in malaria, 345 
Bloom, I. N., 580 
Bone-marrow, 448 
in leukemia, 444 
Bothriocephalus latus, 449 
Bottles, 112 
annealing, 112 
care, 112 

hygeia nursing, 112, 137 
pasteurizing, 112 
Bowles' stethoscope, 54 
Bradycardia, 441 
etiology, 441 
symptoms, 441 
Brain, abscess of, 564 
diagnosis, 564 
etiology, 564 
pathology, 564 
prognosis, 564 
symptoms, 564 
treatment, 565 
at birth, 9 
tumors, 561 
diagnosis, 563 
etiology, 561 

locaHzation symptoms, 561 
pathology, 561 
prognosis, 563 
symptoms, 562 
treatment, 563 
Branchial fistula, 232 

treatment, 233 
Breast-feeding, contra-indications to, 
73 
milk, amount at feeding, 75 
composition, 75 
examination, 75 
supervision, 77 
Brideau, 355 

Bright 's disease, acute, 47") 
Bronchial glands, ;it birth, 4 
tubes, 191 



Bronchial glands — Continued 

foreign bodies in, 192 

diagnosis, 192 

symptoms, 192 

treatment, 192 
Bronchitis, acute catari-hal, 19."! 

diagnosis, 195 

from broncho-pneumonia, 195 

etiology, 193 

pathology, 193 

physical signs, 191 

prognosis, 195 

symptoms, 194 

treatment, 196 
chronic catarrhal, 198 

diagnosis, 204 

pathology, 201 

l^hysical signs, 203 

prognosis, 201 

symptoms, 202 

treatment, 205 
in typhoid fever, 307 
and heart disease, 424 

diagnosis, 198 

pathology, 198 

physical signs, 198 

prognosis, 198 

symptoms, 198 ' 

treatment, 199 
Broncho-pneumonia, 201 
.and heart disease, 424 
in typhoid fever, 307 
Broths, animal, 130 
Brown, 333 
Bruit de diable, 451 
Buccal eruption of measles, 57 
Budin, Pierre, 126 
Bureau of Animal Industrv, 105 
Burns, Wm. Britt, 338 
Busev & Kober, 99 
Buttocks, 16 
Byrd-Dew treatment of asphyxia. 12 



Cabot, 293 

Calcium paracasein, 103 

Calculus, as cause of pyelitis, 473 

Calmette test in tuberculosis, 331 

Calomel vapor inhalations, 61 

Calorie, 126 

Camphor as a stimulant, 61 

Cancarem oris, 226 

Caput succedaneum, 11, 21 

Carbohydrates, 105 

Cascara excreted in milk, 74 

Casein, 102 

action of acid on, 102 



G3i) 



INDEX 



C'asein- — Continued 

calculating amounts in herd milk, 

102 
and citrate of soda, 134 
Cassellberry, 417 
Catarrh, acute gastric, 239 

of conjunctiva, vernal, 183 
Cephalhematoma, differentiation 

from hernia cerebri, 2 
Cereal gruels, percentage, 132 
(Jerebral hemorrhage, 565, 34 

localization, 563, 544 
Cereo, 128 
Certified milk, 85 
Chantard's test for acetone, 248 
Chapin, 119, 121, 617 
cream dipper, 600 
urinal, 469 
Cheyne Stokes respiration, 548, 555 
Chicken-pox, 382 
Chloral, 62 
Chlorosis, 450 

diagnosis, 451 
etiology, 450 
pathology, 450 
prognosis, 451 
symptoms, 450 
treatment, 451 
Cholera infantum, 256 
diagnosis, 258 
definition, 256 
etiology, 256 
pathology, 256 
prognosis, 257 
symptoms, 256 
treatment, 258 
C'horea, 512 
electric, 517 
habit, 516 

diagnosis, 517 
symptoms, 516 
treatment, 517 
hereditary, 516 
etiology, 516 
prognosis, 516 
symptoms, 516 
treatment, 516 
minor, 512 

definition, 512 
etiology, 512 
pathology, 513 
symptoms, 513 
treatment, 514 
in typhoid fever, 307 
posthemiplegic, 514 
Sach's sign of, 49 



Chorea — Continued 
severe, 514 
varieties, 512 
Christian, Frank L., 544 
Churchill-Loper, 394, 490 
Circulation at birth, 1 

fetal, 4 
Circulatory system, diseases of, 422 
Circumcision, 17 
Citrate of soda in breaking up curds. 

134 
Clubbing of fingers in mitral stenosis, 

435 
Cod-hver oil in condensed milk feed- 
ing, 121 
Coit, Henry L., 83 
Colic, 273 

diagnosis, 275 
symptoms, 274 

treatment, during attack, 275 
preventive, 275 
in renal calculus 475 
Colles' law, 354 
Colon, 276 

dilatation of, 276 
diagnosis, 279 
etiology, 276 
pathology, 277 
prognosis, 280 
symptoms, 277 
synonjons, 276 
treatment, 280 
irrigation of, 68 
mega, 276 

bacillus of, cause of pvelitis, 472 
Colostrum, 71, 79 
analysis of, 79 
disagreement, 80 
Comby, 465 
Compensation, in heart lesions, 433 

rupture of, 440 
Condensed milk, 120, 139 
Congenital heart lesions, 423 
Conjunctivitis, 180 
etiology, 180 
symptoms, 180 
treatment, 180 
diphtheritic, 183 
etiology, 183 
pathology, 183 
symptoms, 183 
treatment, 183 
granular, 182 

treatment, 182 
in measles, 365 
phlyctenular, 184 
etiology, 184 



INDEX 



637 



Conjunctivitis — Continued 
pathology, 184 
symptoms, 184 
treatment, 184 
Connor's tables, milk modification, 

595 
Constipation, 269 
etiology, 269 
prognosis, 271 
symptoms, 270 
treatment, 271 
Contagious diseases, 361 
incubation, 417 
quarantine, 417 
Convulsions, 510 
etiology, 510 
prognosis, 511 
symptoms, 511 
treatment, 511 
Convulsive tic, 516 
Cor bovinum, 436 
Cord, umbilical, ligature, 15 
umbilical, dressing, 13 
family disease of, 540 
Cornea, diseases of, 189 

pannus of, 182 
Corona glandis at birth, 9 
Corpuscles, red blood, 444 
Corrigan pulse, 437 
Corsets and depressed nipples, 80 
Cotton, 135 

Counter-irritants, in bronchitis, 62 
Coutts, J. A., 205 
Cow-pox, 384 

Cows, unsuspected but dangerous 
tubercular, 95 
of different breeds, milk from, 101 
milk, 83 

milk and mother's milk, compara- 
tive analysis, 83 
Cowlings, rule for dosage, 58 
Cragin method of milk modification, 

600 
Craniotabes. 357 
Cream dipper, 119 

and whey feeding, 123 
Crede's treatment of eyes, 15 
Cremaster reflex, 507 
Cretinism, 466 

definition, 466 
diagnosis, 466 
etiology, 467 
pathology, 466 
prognosis, 467 
symptoms, 466 
treatment, 467 
Crocker, 585 



Croftan, 470, 471, 472 
Croup, 410 

spasmodic, 155 

diagnosis, from dij^htheiia, 155 
kettle, 156 
Cryptorchid, 9 
Curds in infant stools, 133 
Cushing, 533 
Cyclic vomiting, 247 

diagnosis, 249 

etiology, 248 

prognosis, 251 

symptoms, 248 

treatment, 251 
Cyst, branchial, 233 
Cystitis, 491 

prognosis, 491 

symptoms, 491 

treatment, 491 



Da Costa, 498 

Dactylitis in lues, 356 

Deming milk modifier, 597 

Dermographism, 590 

Dentition, 42 

Dermatitis herpetiformis, diagnosi 

from pemphigus, 579 
Development and growth, MS 
Dextrinizing agents, 128 
Diabetes mellitus, 322 
complications, 323 
definition, 322 
diagnosis, 324 
etiology, 322 
frequency, 322 
pathology, 323 
prognosis, 324 
symptoms, 323 
treatment, 324 
Diagnostic methods in nei-N'ous 

diseas3s, 506 
Diari-hea, from milk, 109 

inflammatory, 259 
Diazo reaction, 306, 309 
Diet after first year, 136 

from twelfth to fifteenth month 

137 
from fifteenth to eighteenth month 

137 
from eighteenth to three years, 
to be avoided after first year. 
Digestive system, diseases of, 22 
Digitalis in heart lesions, 440 
Diluents in milk formula, 127 
Diphtheria, 401 
diagnosis, 409 



137 
13S 

9 



638 



INDEX 



Diphtheria — Continued 

bacteriological, 403 
from croup, 155 
from tonsillitis, 151 
bacteriology, 402 
chart of, 406 
complications, 408 
complications following antitoxin, 

412 
and heart disease, 423 
quarantine in, 418 
cause of nephritis in, 476 
epidemics and milk, 100 
membrane in, 402 
pathology, 404 
symptoms, 405 
treatment, 411 
curative, 411 * 
general, 413 
local, 413 
medicinal, 413 
prognosis, 410 
prophylactic, 411 
Dipper, Chapin cream, 119 
Diseases of digestive system, 222 
ear, 161 
larynx, 142 
nose, 142 
throat, 142 
Distichiasis, 182 
Dobell's solution, 153 
Dropsy in mitral regurgitation, 434 
Drugs excreted by breast , 79 
Dysentery, 259 

Dyspnea, and heart disease, 424 
Dyspepsia, acute, 239 
Dystrophy, progressive muscular, 542 



Ear, diseases of, 177 
middle, 177 

examination, 52 
specula, 52 
Ectropion, 182 
Eczema, 583 

etiology, 583 
pathology, 583 
prognosis, 585 
symptoms, 583 
treatment, 585 
erythematosum, 584 
papulosum, 584 
pustulosum, 585 
squamosum, 585 
vesiculosum, 584 
Edebohls, Geo. M., 480 
Ehrlich, 457 



Electric examinations in nervous 

diseases, 50S 
Emmet ropia, 177 
Emphysema, 149 

compensation in, 200 

etiology, 199 

pathology, 199 

symptoms, 200 

treatment, 200 
and pertussis, 395 
Empyema, 216 

diagnosis, 218 

etiology, 216 

pathology, 217 

physical signs, 219 

prognosis, 217 

symptoms, 217 

treatment, 219 

after, 220 

Encephalitis, acute, 555 

etiology, 555 

pathology, 555 

prognosis, 555 

symptoms, 555 

treatment, 556 
Endocarditis, 430 

etiology, 430 

pathology, 430 

physical signs, 431 

prognosis, 431 

symptoms, 431 

treatment, 431 
chronic, 433 

pathology, 433 
fetal, 438, 439 
malignant, 432 

etiology, 432 

pathology, 432 

prognosis, 433 

symptoms, 432 

treatment, 433 
Enemata, 58 

nutrient, 58 
Enteric fever, 301 

infection, 259 
Enteritis, 259 

from milk, 109 
Enterocolitis, acute, 259 

diet, 265 

duration, 262 

etiology, 259 

hygiene, 266 

pathology, 260 

prognosis, 263 

symptoms, 261 

treatment, 26.') 

general, 265 



INDEX 



G39 



Enterocolitis — Contiiuiod 

medicinal, 265 

preventive, 265 
chronic, 266 

diagnosis, 267 

pathology, 266 

prognosis, 268 

symptoms, 267 
treatment, 268 

dietetic, 26S 

hygienic, 26-8 

medicinal, 269 
Enterocolysis, 60 
Entropion, 182 
Enuresis, 483 

definition, 483 

etiology, 483 

prognosis, 484 

symptoms, 484 

treatment, 484 
Eosinophiles, 445 
Eosinophilia, 446 
Epidemics due to milk, 99 
Epilepsy, 521 

diagnosis, 523 

etiology, 521 

pathology, 521 

prognosis, 523 

symptoms, 523 

treatment, 523 
Epistaxis, 145 

etiology, 145 

symptoms, 145 

treatment, 146 
in atrophic rhinitis, 144 
Epithehal desquamation of tongue, 

224 
Erb's paralysis, 529 

type of muscular dystrophy, 542 
Erysipelas complicating varicella, 383 
Erythema multiforme, diagnosis from 
pemphigus, 579 
nodosum, 459 
in rheumatism, 319 
Eskay's albumenized food, 139 
Esophagitis, 233 

symptoms, 233 

treatment, 233 
Eustacliian tubes at birth, 2 
Examination, methods of, 46 
Exanthemata, cause of nephritis, 476 

cause of pericarditis, 429 
Extremities, upper and lower, at 

birth, 2 
Eye, Crede's treatment of the, 15 
diseases of the, 177 



Eyelids, method of e\'ertJng, 187 
Eyestrain, 177 

Fat, decrease of, in breast feeding, 77 

disagreement of, in breast milk, 77 

increases of, in breast feeding, 77 

in milk, 105 

too much, in milk feeding, 133 
Favus, 576 
Feces, 238 
Feeding, breast, 71 

combined, 82 

difficult cases, 134 

infant, 71 

by rectum, 140 

position for, in intubation cases, 417 
Fetal, circulation, 4 

heart, condition of, inheterotnxia, 9 
Fever blisters, 222, 587 
Finney, J. M., 276 
Fistula, of neck, 232 
symptoms, 232 
treatment, 232 
Fleckern, 361 
Flexner, 425, 550 
Fontanelles, 1 
Food, artificial, 138 

formulae, 130 

to be avoided, 138 

strength of, for different months, 
604, 616 
Foramen ovale, patency of, 423 
Forceps, high, 31 

Foreign bodies in bronchial tubes, 191 
diagnosis, 191 
symptoms, 191 
treatment, 192 

matter in milk, 91 
Fotzke, 539 
Foulouse, 524 
Friedreich's disease, 540 
Frontal bone at birth, 1 
Functional disorders of the heart, 441 
Furunculosis and diabetes mellitiis. 
323 

Gaertner's mother's milk, 138 
Gangrene of cheek, 226 
of lung, 220 

etiology, 220 

pathology, 220 

physical signs, 221 

symptoms, 221 

treatment, 221 
Gargles, 60 
Gastralgia, 252 

diagnosis, 252 



640 



INDEX 



Gastralgia — Continued 
symptoms, 252 
treatment, 252 
Oastrectasia, 246 
(Jastric catarrh, acute, 239 
diagnosis, 240 
etiology, 239 
pathology, 231) 
prognosis, 240 
symptoms, 2;]!) 
treatment, 240 
dilatation, 246 
etiology, 246 
pathology, 246 
prognosis, 247 
symptoms, 247 
treatment, 247 
disorders, 238 
indigestion, acute, 230 
Gastritis, acute, 242 
chronic, 242 
diagnosis, 244 
etiology, 243 
pathology, 244 
prognosis, 244 
symptoms, 244 
treatment, 244 
Gastro-enteric infection, acute, 253 
etiology, 253 
pathology, 253 
prognosis, 254 
symptoms, 254 
treatment, diet, 254 
hygiene, 256 
medicinal, 255 
Gastro-intestinal disease and anemia, 

447 
Gavage, 139 

Gelatin in hemorrhage, 26 
Genitals, care of, in new-born, 16 
Genito-urinary system, disease of, 469 
Genu-valgum in rachitis, 502 
Genu-varum in rachitis, 529 
Geographical tongue, 224 
German measles, 369 
quarantine in, 419 
Gibson, 438 

Glands, bronchial, at birth, 4 
suprarenal, at birth, 6 
thymus, at birth, 6, 462 
tuberculosis, 324 
Gonorrheal infection of mouth, 229 
Graves' disease, diagnosis from tachy- 
cardia, 441 
Griffiths, 311 
Grip, 398 
Growing pains, 318 



Growth and development , 38 
Gruels, 81 

arrowroot, 131 

Keller's method of dextrinizing, 
128 

percentage cereal, 132 
Guiseppe, 231 
Gummata, 357 

Hale's method of milk modificalioii, 

605 
Hamilton's method of milk inodifiea- 

tion, 594 
Hart, E., 99 
Hay bacillus. 237 
Head, at l)irth, 1 
Heart, 422 

defects, 422 
diagnosis, 424 
diseases, 422 
etiology, 422 
examination, 422 
functional disorders, 441 
treatment, 425 
congenital disease, 423 
fetal, 4 

in heterotaxia, 9 

involvement in rheumatism, 318 
palpation of, 53 
Heat, effect of, on milk, 111 
Hemic murmurs, 448 
Hematuria in purpura, 459 
Hemiplegia, spastic, 559 
Hemoglobin in chlorosis, 450 
pernicious anemia, 448 
pseudo-leukemia, 456 
scale, Tallquist, 444 
Hemoglobinometer, Von Fleischel's, 
444 
Oliver's, 444 
Hemophilia, 460 
diagnosis, 460 
etiology, 460 
pathology, 460 
prognosis, 460 
symptoms, 460 
treatment, 460 
Hemorrhage, cerebral, 34 
and enema, 447 

in cord, diagnosis from myelitis, 535 
intra-cranial, 565 
cerebral, 565 

etiology, 565 
prognosis, 565 
symptoms, 565 
treatment, 5()6 
subdiu'al, 565 



INDEX 



G41 



Hemorrhage — Continued 
of new-born, 23 
etiology, 23 
location, 24 
prognosis, 25 
treatment, 26 
in typhoid fever, 306 
umbilical, 22 
Hereditary mania, 519 
spastic paralysis, 541 
Heredity in malaria, 345 

and leukemia, 453 
Hernia, umbilical, 526 
cerebri, 21 
in pertussis, 395 
Herpes, 222, 587 
diagnosis, 587 
facialis, 587 
genitalis, 587 
labiahs, 587 
symptoms, 587 
treatment, 587 
zoster, 587 

definition, 587 
diagnosis, 588 
etiology, 587 
symptoms, 588 
treatment, 588 
in rheumatism, 318 
Herz's arm test in rheumatism, 318 
Heterotaxia, 9 
Hess refrigerator, 623 
Heubner, 126 
Hirschprung's disease, 276 
Hives, 589 

Hodgkins' disease, 456 
Holt's milk set, 75 
Hookworm disease, 286 
Hordeolum, 178 
etiology, 178 
symptoms, 179 
treatment, 179 
History card, 47 
Hydrocephalus, acute, 556 
etiology, 556 
pathology, 55!) 
prognosis, 556 
symptoms, 556 
treatment, 557 
chronic, 557 
diagnosis, 558 
etiology, 557 
prognosis, 558 
sjanptoms, 557 
treatment, 558 
Hydronephrosis, 482 
definition. 482 



Hydronephrosis- — Continued 
etiology, 483 
pathology, 483 
prognosis, 483 
symptoms, 483 
treatment, 483 
Hydrotherapy in endocarditis, 4: 
Hydrothorax, 57, 438 
Hyperopia, 177 
Hypodermoclysis, 60 
Hysteria, 518 

diagnosis, 519 
symptoms, 518 
treatment, 520 
in chlorosis, 412 
mental manifestations in, 519 
motor manifestations in, 519 
sensory manifestation in, 51 S 
Hvsterical mania, 519 



Icterus in new-born, 28 
Idiocy, Lorain type, 466 
Ileocolitis, 259 
Imperial granum, 139, 138 
Impetigo, contagiosa, 577 
diagnosis, 578 
etiology, 577 
pathology, 578 
symptoms, 578 
treatment, 578 
Inanition, 493 

Incubation and quarantine of conta- 
gious diseases. 417 
Indigestion, diagnosis from appendi- 
citis, 293 
acute gastric, 239 
Infant feeding, 71 

care of, in hot w^eather, 610 
Infantile paralysis, 530 
Infantilism, diagnosis from ci-etiii- 
ism, 467 
of Lorain type, 467 
Infectious diseases cause of heart 

lesions, 423, 442 
Influenza, 398 
Inhalation, 59 

Inoculation treatment in niiIn'o- vagi- 
nitis, 490 
Inspection of child, 49 
Insufflation in asphj-xia, 12 
Intertrigo, 16, 567 

treatment, 567 
Intestinal parasites. 281 
Intestines, 236 
bacteria of, 237 
dieases of, 236 



642 



INDEX 



Intestines — Continued 
surgical condition of, 289 
tuberculosis of, 325 
Intubation, 414 
indications, 415 
operation, 415 
Intussusception, 296 
diagnosis, 298 
etiology, 296 
pathology. 296 
prognosis, 299 
symptoms, 297 
treatment, 299 
Intussusceptum, 296 
Intussuscipiens, 296 
Inunction, 70 
Irrigation of colon, 68 
Itch, 571 

Jelly, oatmeal, 132 
Juice, beef, 130 
Junket, 130 

Kelly, 295 

Keloid and vaccination, 387 

Kentucky's law and certified milk, 

85 
Keratitis, phlyctenular, 189 
etiology, 189 
symptoms, 189 
treatment, 189 
interstitial, 189 
pathology, 190 
symptoms, 190 
Kerley, 121, 127, 139, 315, 618 
Kernig's sign, 41, 508 

in cerebrospinal meningitis, 551 
Kidney, at birth, 5 
tumors, 481 
diagnosis, 482 
etiology, 481 
prognosis, 481 
symptoms, 481 
treatment, 481 
benign, 481 
sai-coma, 481 
tuberculosis, 325 
Kilmer, T. W., 397 
Klebs-Loeffler bacillus, 183, 40] 
Knee-jerk, 507 
Kober and Busey, 99 
Koch, 94 
Koplik, 363 
spots, 51 
Kumyss, 131 

Laboratory, milk, 114, 117 
Walker Gordon, 114 



Laborde treatment ot asphyxia, 12 

Lactalbumin, ;103 

Lactation history, 80 

Lactic acid bacteria, 91 

Lactoglobulin, 103 

Lactone tablets, 132 

Ladd's cereal decoction, 129 

tables milk modification, 602 
La grippe, 398 

complications, 400 

etiology, 398 

pathology, 399 

prognosis, 400 

symptoms, 399 

treatment, 400 
Landouzy-Dejerine type of muscular 

dystrophy, 542 
La Noble's test for acetone, 249 
Lanugo, 20 
Larrier, Nathan, 335 
Laryngitis, acute catarrhal. 155 

diagnosis, 155 

etiology, 155 

prognosis, 156 

symptoms, 155 

treatment, 156 
in measles, 365 
Laryngismus stridulus, 156 
Larynx at birth, 22 

diseases of, 142 
Leach, 101 

Leishman's stain, 343 
Leucocytes, degenerated, 445, 446 
Leucocytosis in appendicitis, 293. 
447 
neutrophilic, 446 
Leucopenia, 446 
Leucorrhea in chlorosis, 451 
Leukemia, lymphatic, 453 
Lieben's test for acetone, 249 
Lichen urticatus, 589 
Lips, disease of, 222 
Liver, at birth, 55 
Lockjaw, 34 
Loeffler's solution, 149 
Lorain type idiocy, 467 
Lues, 354 
Lumbar puncture, 509 

in cerebrospinal meningitis. 554 
Lungs, at birth, 3 

gangrene of, 220 
Lymphatic glands, disease of, 462 
leukemia, 453 

definition, 453 

acute form, 453 

myeloid, 453 
diagnosis, 454 



INDEX 



Lymphatic gluucls — Coiitiimed 

pathology, 453 

prognosis, 454 

symptoms, 454 

treatment, 455 
chronic form, 455 

diagnosis, 456 

etiology, 455 

pathology, 455 

})rognosis, 456 

syniptoiris, 455 

treatment, 456 
Lymphocytes, 445 
Lympliocyto.sis, 443, 456 
Lymphoma, 45!) 

McBurney, 292 
McElroy, 338 
Malaria, 338 

definition, 338 
etiology. 340 
pathology, 346 
symptoms, 348 
treatment, 353 
and anemia, 447 
blood picture in, 345 
heredity, 345 
historical note, 339 
prophylaxis, 350 
staining, 344 
susceptibiHty, 345 
in typhoid fever, 311 
Mai, grand, 522 

petit, 521 
Malnutrition, 493 
Malt soup, 129 
Mania, hysterical, 520 
Marasmus, 493 
Masem, 361 
Mason, 362 
Mast cells, 445 
Mastitis, in new-born, 32 
Mastoid cells at birth, 2 
Mastoiditis, 175 
diagnosis, 175 
etiology, 175 
prognosis, 176 
symptoms, 175 
treatment, 176 
Masturbation and thread worms, 282 
Materna, Hass, 595 
^laxilla, inferior at birth, 2 
Measles, 361 

complications and sequelae, 364 
definition, 361 
diagnosis, 366 
from rubella., 366 



Measles — Con t i n ued 

from drug eruptions, 367 
from scarlatina, 367 
etiology, 361 
eruption, 363 
prognosis, 366 
symptoms, 362 
synonyms, 361 
treatment, 367 
atypical cases, 361 
malignant. 364 
quai-antine, 418 
Meconium, 16, 238 

ditt'erentiation from meleiia, 25 
^ledicinal antipyretics, (il 
3Jega colon, 276 
:\Iegaloblasts, 445, 447 
Megalocytes, 445 
Meige, 467 
xMelena, 23. 498 
Mellin's food, 1:58, i;;9 
Meninges, tuberculosis of. 325 
tumors of, 561 
diagnosis, 563 
etiology, 561 
localization, 563 
l)athology, 561 
prognosis, 563 
symptoms, 562 
treatment, 563 
Meningitis, epidemic cerebi'osijinal, 
510, 551 
bacteriology 550 
diagnosis, 553 
etiology. 550 
pathology. 551 
prognosis, 552 
symptoms, 551 
treatment, 554 
simple acute, 545 
diagnosis, 546 
etiology, 545 
pathology, 546 
prognosis, 546 
symptoms, 546 
treatment, 546 
tubercular, 510, 547 
diagnosis, 549 
etiology, 547 
pathology, 547 
prognosis. 549 
symptoms, 547 
treatment, 550 
Menstruation, 45 

and epistaxis, 145 
changes in. in chlorosis, 451 
Mensuration, 57 



644 



INDEX 



Microblasts, 445, 447 
Micrococcus lanceolatiis, 425 
Microcytes, 444 
Microsporon anclonini, 573 
Microsporosa trachomatorum, 181 
Middle ear, examination, 52 
Miliaria, 319 

Milk, analysis of different animals, 
101 
analysis of, by Babcock, 105 

by Van Slyke, 105 
bacteria in, 237 
bacterial count, 92 
blue discoloration, 91 
breast, 75 

coming of, 71 
composition of, 75 
examination of, 75 
too small amount of, 81 
care of in home, 108 

on journey, 136 
casein, 102 

cause of epidemics, 99 
certified, 83 

and Kentucky law, 85 
shipping case, 87 
changes in, caused by bacteria, 91 
clean and cold, 91 
Commissions, Medical, 
American Association, 83 
Jefferson County, 86 

rules, of, 89 
New York City, 86 
rules of, 86 
condensed, 120 
analysis, 120, 121 
cause of. rachitis, 500 
cow's, 83 

and human, comparative analysis, 

83 
of different breed, 101 
diluents in, 127 
and distillery waste 94 
effect of heat on. 111 
fat in, 105 
feeding, symptoms of disagreement 

of, 133 
influence of, on, mortality statistics, 

109 
market, 94 
modifications, 591 
Barnes' formulae, 591 
by Deming modifier, 595 
by Hass Materna, 595 
Connor's tables, 595 
Hale's method, 605 
Hamilton's, 589 



Milk — Continued 

Ladd's tables, 602 
Sloane maternity milk set, 600 
Westcott's .formula?, 594, 593 
modified, 113, 616 
laboratory, 117 
pasteurization, 110 
peptonized, 122 
set. Holt's, 75 
slimy and ropy, 91 
sterihzation, 110 
and tuberculosis, 94 
Mitral regurgitation, 434 
pathology, 434 
physical signs, 434 
prognosis, 435 
symptoms, 434 
stenosis, 435 
pathology, 435 
physical signs, 435 
prognosis, 436 
symptoms, 435 
Modified milk, 113 

prescription blank, 114, 115 
Mohler, 96 

Mongolian idiocy, 467 
Morbilh, 361 
Morbus maculosis, 459 

ceruleus, 424 
Morrow, 359 
Morse, 294 
Mosenthal, 394 
Moulding of head, 1 
Mouth breathing, 158 
care of, in newborn, 15 
disease, 224 
examination, 51 
gonorrheal infection. 22!) 
symptoms, 229 
treatment, 229 
Mother, nursing, 73 

diet of, 73 
Muguet, 228 
Mumps, 397 

Murphy's saline injection, 141 
Muscular dystrophy, progressive, 512 
etiology, 542 
pathology, 542 
prognosis, 545 
symptoms, 542 
treatment, 545 
Mustard plasters, 62, 66 
Mya's disease, 276 
Myelitis, a-cute, 533 
diagnosis, 534 
etiology, 533 
pathology, 533 , 



INDEX 



64; 



Myelitis — Continued 

prognosis, 534 

symptoms, 533 

treatment, 534 
Myelocyte, 746 
Myocarditis, acute, 442 

etiology, 442 

pathology, 442 

prognosis, 442 

symptoms, 442 

treatment, 442 
Myopia, 177 
Myxedema, 406 

Napkins, care of, 18 

rubber, 16 
Nasal polypi, 146 
symptoms, 146 
treatment, 146 
Nasopharynx, at birth, 2 
Neonatoium, ophthahnia, 185 
Nephritis, acute parenchymatou; 
etiology, 476 
pathology, 476 
prognosis, 477 
symptoms, 477 
treatment, 477 
diet, 478 
medicinal, 478 
management, 478 
prophylaxis, 477 
chronic interstitial, 480 
etiology, 480 
pathology, 480 
prognosis, 481 
symptoms, 480 
treatment, 481 
chronic parenchymatous, 479 
diagnosis, 480 
etiology, 479 
pathology, 479 
prognosis, 480 
symptoms, 479 
treatment, 480 
Nervous system, diseases of, 506 
diseases, organic, 526 
diagnostic methods in, 506 
functional disorders. 510 
Nestle's Food, 138, 139 
Nettle rash, 589 
Neucleoalbumin in urine, 470 
Neuritis, multiple, 526 
etiology, 526 
pathology, 526 
prognosis, .>27 
symptoms,^527 
treatment 527, 



Neusholme, 110 
Newborn, 10 

atelectasis in, 28 
bathing, 16 
care of, 13 
diseases of, 21 
dressing of, 15 
hemorrhage of, 23 
icterus in, 28 
injuries of 21, 31 
mastitis in, 32 
sepsis of, 29 

starvation temperature in, :V2 
temperature of, 20 
umbilical hernia, 27 
urine of, 20 
New York City ^lilk Connnission, 86 
Nipple, care of, 71, 72, 112 
acid boracic in, 2 
cracked or eroded, 71 
depressed and corsets, 80 
147 training of depressed, 80 

Nodules, subcutaneous, in rheuma- 
tism, 319 
Noma, 226 

Normoblasts, 445, 447 
Nose at birth, 2 
diseases of, 142 
examination of, 53 
foreign bodies in, 53 
irrigation of, 66 
Nursery, 19 

air space of, 19 
Nursing, contraindications lo, 73 
bottles, 137 
interval at birth, 71 
method of, 74 
mother, 73 

bowels of, 74 
diet of, 73 
Nutritional disorders, 493 

Oatmeal jelly, 132 
O'Dwyer, Jos., 414 

intubation set, 59 
Ohver's hemoglobinometer, 444 
Operation in appendicitis, 295 
Ophthalmia neonatorum, 185 
etiology, 185 

case of, 186 

focal symptoms, 185 

prognosis, 186 

prophylaxis, 185 

sequelae, 186 

treatment, 186 
Ophthalmic test in tuberculosis, 331 
Opium. 62 



046 



INDEX 



Oppenheim, 539 
Optic neuritis, 563 
Orthopnea and heart disease, 424 
Otitis media, in typhoid fever, 307 
acute catarrhal, 166 
etiology, 166 
pathology, 166 
prognosis, 16 ' 
symptoms, 166 
treatment, 167 
acute suppurative, 169 
etiology, 169 
prognosis, 172 
symptoms, 169 
treatment, 172 
differential diagnosis of, 173 
in measles, 365 
in scarlatina, 375 
temperature curve of, 171 
Outfit for baby, 18 
Ovaries at birth, 9 
Oxyuris vermicularis, 281 
description, 281 
diagnosis, 282 
symptoms, 282 
treatment, 282 
Ozena, 144 

Pack, wet cool, 65 
Palpation, 53 

rectal, 54 
Palsies, cerebral, 559 
diagnosis, 560 
etiology, 559 
pathology, 559 
prognosis, 560 
symptoms, 559 
treatment, 560 
Palsy, Bell's, 528 
facial, 528 
etiology, 528 
prognosis, 528 
symptoms, 528 
treatment, 528 
Pannus of cornea, 182 
PaqueUn cautery in cancrum oris, 

227 
Paracasein calcium, 103 
Paracentesis of drum, 166 
Paraphimosis, 486 

treatment, 486 
Paraplegia, spastic, 559 

in syphilis of cord, 538 
Paralysis, hereditary spastic, 541 
cerebral type, 541 
cerebrospinal type, 542 
diagnosis, 542 



Paralysis — Continue( I 
prognosis, 542 
treatment, 542 
Erb's, 529 

prognosis, 529 
treatment, 530 
infantile, 530 
obstetrical, 529 
spinal type, 541 
Parasites, benign tertian of malaria, 
342 
estivoautunmal, of malaria, 342 
intestinal, 281 
Parasitic skin lesions, 568 
Park, 403 
Parotitis, 379 

comphcations, 398 
etiology, 397 
prognosis, 398 
symptoms, 397 
treatment, 398 
Pasteurization of milk, 110 
Pasteurized milk, bacteria in, 112 
Patterns for baby's clothes, 1 8 
Pediculosis, 568 
capitis, 568 
diagnosis, 569 
treatment, 569 
corporis, 570 
diagnosis, 570 
treatment, 570 
pubis, 570 
Peliosis rheumatica, 320 
Pellagra, 336 

diagnosis, 337 
etiology, 336 
pathology, 338 
prognosis, 338 
symptoms, 336 
treatment, 338 
Pemphigus vulgaris, acute, 579 
diagnosis, 579 
etiology, 579 
pathology, 579 
prognosis, 580 
sj^mptoms, 579 
treatment, 580 
foiiaceous, 579 
neonatorum, 579 
vegetans, 579 
Peptogenic milk powder, 138, 139 
Peptonized milk, 122 
Percentage system of feeding, 113 
Percussion. 56 
hammer, 57 
Perforation in typhoid fever, 306 



INDEX 



647 



Pericarditis, 425 

diagnosis, 425 

etiology, 425 

occurrence, 426 

pathology, 425 

physical signs, 425 

prognosis, 426 

symptoms, 426 

treatment, 427 
chronic, 428 

etiology, 429 

pathology, 429 

symptoms, 429 

treatment, 429 
fibrinous, 425 
forms of, 425 
plastic, 425 
with effusion, 427 

pathology, 427 

prognosis, 428 

symptoms, 427 

treatment, 428 
Perinephritis, 475 

diagnosis, 476 

definition, 475 

etiology, 475 

pathology, 475 

sjrmptoms, 475 

treatment, 476 
Peritonsillar abscess, 153 

etiology, 153 

prognosis, 153 

symptoms, 153 

treatment, 153 
Perleche, 222 

etiology, 222 

symptoms, 222 

treatment, 223 
Pertussis, 392 

comphcations, 395 

diagnosis, 395 

etiology, 392 

pathology, 393 

prognosis 395 

symptoms, 393 

treatment, 395 
Peterson, 561 
Pfeiffer bacillus, 399 
Pharyngitis, in measles, 365 
Phenolphthalein, 273 

and breast milk, 75, 94 
Phimosis, 485 

symptoms, 485 

treatment, 486 
Phlyctenular keratitis, 189 

etiology, 389 



Phlyctenular keratitis — Continued 

symptoms, 189 

treatment, 189 
Pills, 58 
Plasmodium malariae, 340 

vivax, 342 
Pleurisy, 213 

diagnosis, 215 

from appendicitis, 294 

etiology, 213 

pathology, 213 

physical signs, 211 

prognosis, 215 

symptoms, 214 

treatment, 216 
Pneumococcus, in tonsillitis, 149 
Pneumohydrothorax, 57 
Pneumonia, broncho-, 201 

diagnosis, 204 

etiology, 201 

pathology, 201 

physical signs, 203 

prognosis, 201 

symptoms, 202 

treatment, 205 
differential diagnosis, from appen- 
dicitis, 293 
lobar, 206 

diagnosis, 207 

etiology, 206 

pathology, 206 

^physical signs, 208 

prognosis, 211 

symptoms, 206 

termination, 208 

treatment, 211 
and measles, 365 
Poikilocytes, 445 
Poikilocytosis, 447, 450 
Poliomyelitis anterior acuta, 530 

diagnosis, 532 

etiology, 530 

pathology, 530 

prognosis, 532 

symptoms, 531 

treatment, 533 
Politzer bag, 165 
Politzeration, 165 

Polymorphoneuclear neutrophilic leu- 
cocytes, 445 
neutrophiles, 449 
Polypi, nasal, 146 

symptoms, 146 

treatment, 146 
Pott's disease, 530 

diagnosis, 536 

prognosis, 536 



648 



INDEX 



Pott's Disease — Continued 
symptoms, 536 
treatment, 536 
Powders, 58 
Poynton, 426, 429, 431 
Prescription blank for modified milk, 

113 
Presystolic thrill, 435 
Progress report, 40 
Proteid disagreemen in breast milk, 
80 
increase of, in breast feeding, 77 
too much, in milk feeding, 133 
of milk, chemistry of, 102 
Prvu-itus, 588 

treatment, 589 
ani, 589 

in diabetes mellitus, 323 
Pseudohypertrophy of muscles, 542 
Pseudoleukemia, 456 
definition 456 
diagnosis, 457 
pathology, 456 
prognosis, 457 
symptoms, 456 
treatment, 457 
infantum, 457 
definition 457 
etiology, 457 
pathology, 457 
symptoms, 458 
treatment 458 
Pseudopernicious anemia, 457 
Pterygium, 188 
etiology 188 
symptoms, IhS 
treatment, 189 
Pulmonary collapse, 192 

lesions, in rheumatism, 320 
Pulse, Corrigan's 437 
water hammer, 437 
Purpura, 458 

pathology, 458 

prognosis, 459 

treatment, 460 

fulminans, 459 

hemorrhagica, 459 

in rheumatism, 317 
Henoch's, 459 
rheumatica. 459 
simplex, 458 

symptoms of, 458 
Pyelitis, 472 

definition, 472 
diagnosis, 473 
etiology, 472 
prognosis, 473 



Pyelitis — Continued 

symptoms, 472 

treatment, 474 
in typhoid fever, 311 
Pyelonephritis, 472 
Pylorus, stenosis of, 234 

symptoms, 234 
Pyonephrosis, 472 
Pyopericardium, 429 

etiology, 429 

pathology, 429 

prognosis, 430 

symptoms, 429 

treatment, 430 

Quadriplegia, 560 

Quartan parasite, malaria, 341 

Quassia in treatment of thread worms 

283 
Quinsy, 153, 410 

Rachitis, 500 

diagnosis, 503 

from chronic hydrocephalus, 55- 
from rheumatism, 320 
etiology, 500 
pathology, 500 
prognosis, 503 
symptoms, 500 
focal, 501 

systemic, 502 ^ 

treatment, 503 
medicinal, 504 
and anemia, 447 
Ramogen, 138, 125 

analysis, of, 125 
Ranula, 230 

symptoms, 230 

treatment, 230 

Rectal feeding, 140 

palpation, of 
Renal calculus, 474 
etiology, 474 
symptoms, 474 
treatment, 475 
colic in calculus, 475 
decapsulation, 480 . 
Regurgitation, 433 

mitral, 434 
Report of progress, 40 
Respirations in newborn, 10 
Retropharyngeal abscess. 154 
Reynolds' test for acetone, 249 
Rhagades, 357 
Rheumatism, 317 

complications, 319 
diagnosis, 320 



INDEX 



049 



Rheumatism — Continued 
from scorbutus, 49S 

duration, 319 

etiology, 317 

pathology, 317 

prognosis, 329 

symptoms, 317 

treatment, 320 
as cause of heart disease, 423 
skin lesions in, 319 
subcutaneous nodules in, 319 
tonsillitis in, 319 
Rhinitis,- acute, 142 

diagnosis, 143 

etiology, 142 

pathology, 142 

symptoms, 142 

treatment, 143 
atrophic, 144 

etiology, 144 

prognosis, 144 

symptoms, 144 

treatment, 144 
chronic, 143 
Richardson, 295 
Riga's disease, 231 

symptoms, 231 
Ringworm, 572 

Robinson's patent barley, 129 
Romanowskv's stain, 343 
Rosen.xu, M.^ J. 192 
Rotch, T. M., 114, 117, 135, 359, 428, 

448 
Rotheln. 369 
Royer, B. Franklin, 552 
Rubella, 389 

compHcations, 371 

diagnosis, 371 

etiology, 369 

l^rognosis, 371 

symptoms, 370 

treatment, 371 
Rubeola, 361 

Sachs, 542 

sign of chorea, 49 
St. Vitus' dance, 512 
Salmon, 98 

Salts, inorganic, in nlilk 105 
Sarcini ventriculi, 237 
Sarcoma of kidney, 481 
Sattler's double coccus, 181 
Scabies, 571 

diagnosis, 5 "2 

symptoms, 571 

treatment, 572 
Scalp, ringworm of, 574 



Scarlatina, 372 

complications, 375 
diagnosis. 377 
etiology, 372 
prognosis, 377 
quarantine, 418 
symptoms, 373 
treatment, 377 
prophylactic, 377 
spnptomatic, 379 
and heart disease, 423 
Scarlet fever epidemics and milk. 99, 

100 
Scharlach, 372 
Schamberg, 590 

Schultz treatment of asphyxia, 13 
Sclerema, 36 

Sclerosis of spinal cord, 539 
diagnosis, 540 
etiology, 539 
pathol.:)gy, 540 
prognosis, 540 
s^mptomis, 539 
treat nent, 540 
Scorbutus. 497 

diagnosis from rheumatism, 319 
and anemia. 448 
Scoi'e cords, 105 
Scraped beef, 132 
Scurvy, 497 

diagnosis, 498 
etiology, 497 
pathology, 497 
prognosis, 499 
symptoms, 497 
treatment, 499 
Scutulum in favus, 576 
Searcy, 336, 338 
Seat worm, 281 

Sensation in nervous diseases, 507 
Sepsis of newborn, 29 
Sera, animal, in hemorrhages, 26 
Serum albumin, 470 
Shield, nipple, 71 
Shiga bacillus, 237 
Shingles, 587 
Sigmoid flexure, 5 

Silver solution in o{)hthalinia neona- 
torum, 187 
Sinapism, mustard. (\'A 

turpentine, 60 
Skin, 

di.seases of, 567 
examination, 53 
lesions in rheumati.sm. 319 
of newborn, 14 



650 



INDEX 



Sleep, disorders of, 525 

Sloane milk modifier, 600 

Smallpox, 328 

Smith, J. Lewis, 550 

Smith, Letchworth, 610 

Snow, 298 

Snyder, 288 

Soor, 228 

Southworth, 123 

Spastic paralysis, hereditary, 541 

paraplegia, 538 
Sphenoid bone at birth, 1 
Sphincter ani, dilatation of, in asphyxia, 

13 
Specula, ear, 52 
Spina bifida, 2 
Spinal cord, diseases of, 530 
sclerosis of, 539 
etiology, 539 
pathology, 539 
sjTnptoms 539 
syphilis of, 538 
diagnosis, 538 
pathology, 538 
spastic paraplegia in, 538 
treatment, 538 
tumors of, 537 
diagnosis, 537 
prognosis, 537 
symptoms, 537 
treatment, 537 
Spleen, at birth, 5 
Spotted fever, 550 
Squires' sign, 508 
Staining malaria parasite, 344 
Stanton's percussion hammer, 57 
Staphylococcus in tonsillitis, 149 
Starch, digestion, as shown by stools, 

127 
Starr, 531 

Starvation temperature, 32 
Statistics, mortality and morbidity 

influenced by milk, 109 
Status lymphaticus, 462 
Steelyards for weighing, 41 
Stenosis, 433 

of pylorus, 234 
Sterihzation of milk, 110 
Sternum at birth, 2 
Stethoscope, 54 
Still born, 10 
Stimulants, 61 
Stomach, at birth, 5 
bacteria in, 237 
diseases of, 236 
washing, 66 



Stomatitis, 224 

symptoms, 225 
treatment, 225 
gangrenous, 226 
etiology, 226 
pathology, 227 
prognosis, 227 
symptoms, 227 
treatment, 227 
herpetic, 225 
etiology, 225 
pathology, 225 
symptoms, 225 
treatment, 225 
syphihtic, 230 
ulcerative, 225 
etiology, 226 
pathology, 226 
symptoms, 226 
treatment, 226 
Stone in kidney, 474 
Stools, curds in, 133 

number in 24 hours, 237 
Strawberry tongue, 52, 377 
Streptococcus, in tonsillitis, 149 
Stye, 178 
Subcutaneous nodules in rheumatism, 

319 
Sudamina, 319, 568 
treatment, 568 
Sugar, too much in milk feeding, 133 
of milk solution at birth, 72 
solution, 120 
Suppositories, 59 
Suprarenal glands at birth, 6 
Surgery of intestines, 289 
Sutures at birth, 1 
Sydenham's chorea, 512 
Sylvester treatment of asphyxia, 12 
Symblepharon, 182 
Synovitis, in syphilis, 357 
Syphilis, congenital, 354 
diagnosis, 358 
etiology, 354 

mode of transmission, 355 
pathology, 355 
prognosis, 358 
treatment, 358 

of special symptoms, 359 
and anemia, 447 
of spinal cord, 538 
Syringe for enemata, 59 

Tabes and Friedreich's disease, 541 
Tache cerebrale in tubercular menin- 
gitis, 549 



INDEX 



651 



Tachycardia, 441 

prognosis, 442 

symptoms, 441 

treatment, 441 

auscultation in 442 

Talbot, 133 

Tallquist hemoglobin scale, 444 
Tape for mensuration, 57 
Teeth, temporary and permanent, 43 
Temperature, 49 . 
method of taking, 50 
of newborn, 20 
starvation, of newborn, 32 
Temporal bones at birth, 2 
Tenia, 284 

symptoms, 285 
treatment, 285 
mediocannellata, 281, 285 
solium, 281, 285 
Testicles, at birth, 9 

undescended, operation for, 491, 492 
Tetanus, 34 
Therapeutics of infancy and childhood, 

58 
Thermos bottle as cause of illness from 

changes in milk, 109 
Thorax at birth, 2 
Threadworms, 281 
Thrill, presystoKc, 435 
Throat, diseases of, 142 

examination of, 50 
Thrush, 15, 228 
etiology, 228 
symptoms, 228 
treatment, 229 
Thymus gland, 462 
at birth, 4 
enlarged, 462 

symptoms, of, 462 
Tinea circinata, 573 
pathology, 573 
symptoms, 573 
treatment, 573 
favosa, 576 
diagnosis, 576 
etiology, 576 
pathology, 576 
prognosis. 576 
symptoms, 576 
treatment, 577 
tonsurans, 574 
diagnosis, 574 
etiology, 574 
pathology, 574 
symptoms, 574 
treatment, 575 



Tongue depressor, 52 
diseases of, 224 
epithehal desquamation, 225 
examination of, 52 
of scarlet fever, 52 
strawberry, 377 
tie, 231 

treatment, 231 
Top milk, method of modification, 

119 
Tonsillitis, acute catarrhal, 148 
treatment, 149 
follicular, 149, 408 
comphcations, 151 
diagnosis, 151 
duration, 150 
etiology, 149 
symptoms, 150 
treatment, 151 
in rheumatism, 319 
Tonsillotome, 152 
Tonsils, chronically enlarged, 151 

diseases of, 146 
Trachea, at birth, 2 
Trachoma, 181 
etiology, 181 
pathology, 181 
prognosis, 181 
sequela, 182 
symptoms, 181 
treatment, 182 
roUer forceps for, 182 
Transfusion of blood in pernicious 

anemia, 550 
Tricuspid regurgitation, 438 
pathology, 438 
physical signs, 439 
prognosis, 439 
symptoms, 438 
stenosis, 439 
etiology, 439 
pathology, 439 
physical signs, 439 
symptoms, 439 
Tubercle bacillus, bovine and human 

type, 96 
Tuberculin, 331 

test for cattle, 97 
Tuberculosis, 324 
chart of, 326 
diagnosis, 330 

cutaneous method, 332 
from pseudoleukemia, 451 
from bronchopneumonia, 264 
frequency of, 326 
ophthalmic test of, 331 
pathology, 324 



652 



INDEX 



Tuberculosis — Continued 

port of entry, 325 

prevention, 334 

symptoms, 327 

treatment, 334 
and anemia, 447 
and measles, 365 
and milk, 94 
and pertussis, 395 
in typhoid fever, 310 
of adrenal glands, 465 
glands, 324 
intestines, 325 
kidney, 325 
meninges, 325 

transmission of, through milk, cases, 
95 

Tubotympanic, catarrh, 164 

differential diagnosis of, 173 

Turbinates, hypertrophied, 53 

hypertrophy of, in rhinitis, 144 

Typhoid fever, 301 

age, 301 

bacteriology, 302 

chart of, 307 

complications, 306 

definitions, 301 

diagnosis, 309 

duration, 303 

etiology, 301 

incubation, 303 

pathology, 302 

prognosis, 311 

prophylaxis, 311 

symptoms, 303 
aphasia in, 308 
appendicitis, 311 
bowels in, 315 
chorea in, 307 
convalescence, 316 

diet in, 317 
diet in, 313 

Ehrhch's reaction, 306, 307 
epidemics and milk, 99 
fever, 314 
furunculosis in, 309 
hemorrhage in, 306, 316 
malaria in, 311 
management, 312 
otitis media in, 307 
perforation in, 306 
pyelitis in, 311 
stimulation, 314 
tuberculosis, 310 
tympanites, 316 
Widal test, 306, 309 



Ulcerations at angle of mouth, 222 
etiology, 222 
symptoms, 222 
treatment, 223 
Umbilical cord, dressing of, 13 
ligature of, 13 
hernia, 5, 27 
Uncinaria duodenahs, 281 
Urethra, male, at birth, 6 
Urethritis, 487 
gonorrheal, 488 
diagnosis, 488 
symptoms, 488 
treatment, 488 
Uric acid, 469 
Urinal, Chapin, 469 
Urine, collection for examination, 69 
incontinence of, 483 

in pertussis, 395 
in infants and children, 460 
in pyelitis, 473 
of newborn, 20 
Uriticaria, 589 
etiology, 589 
pathology, 589 
prognosis, 590 
symptoms, 589 
treatment, 590 
factitata, 590 
in rheumatism, 320 
in vaccination, 387 
Uvulitis, 152 

symptoms, 152 
treatment, 153 

Vaccination, history of, 385 
technic of, 385 
virus, selection of, 385 
Vaccinia, 384 

complications, 387 
history, 384 
symptom, 384 
Vail's method of everting the lids, 187 
Valvular lesions, combined, 438 
of heart congenital 423 
treatment, 440 
Van Slyke, 104, 105 
Vapor, calomel, inhalations, 61 
Varicella, 382 

comphcations, 383 
etiology, 382 
gangrenosa, 383 
prognosis, 384 
quarantine, 419 
symptoms, 382 
systemic, 383 
treatment, 384 



INDEX 



653 



Variola, 388 

complications, 390 

definition, 388 

diagnosis, 390 

etiology, 388 

prognosis, 390 

prophylaxis, 418 

quarantine, 418 

symptoms, 388 

treatment, 391 
\'ernal catarrh of conjunctiva, 183 
Vernix caseosa, 14 
Version, 31 

Vision in nervous diseases, 508 
Vissman, Dr. Louis, 99 
Vomiting, cyclic, 247 
Von Jaksch, 457 
Von Pirquet, 332, 413 
Vulvovaginitis, 488 

complications, 490 

etiology, 488 

prognosis, 490 

symptoms, 488 

treatment, 490 - 

Wallace, 296 

^^ angenbrand, 22G 

^^ ater, to nursing baby, 72 

\\ asting disease, 493 



Wax, impacted, in auditory canal, 163 

treatment, 163 
Weaning, 82 
Weeks' bacillus, 180 
Weight, tables for calculation, 41 
Werhof's disease, 459 
Westcott's chart for milk modifica- 
tions, 594 

formulae for milk modifications, 592 
Whey, 122 

mixtures, cream, 603 
feeding, 123 
Whitehall-Tatum bottle, 112 
Whooping-cough, 392 

quarantine in, 418 
Widal reaction, 305, 309 
Wilcox, 322 
Winckel's disease, 23 
Wolff-Eisner, 333 
Wine whey, 124 
Worm, hook, 286 

pin, 281 

round, 283 

seat, 281 

tape, 284 

thread, 281 
Wright's method of inoculation in vul- 
vovaginitis, 490 

stain, 445 
Young's rule for dosage, 58 



stv 



6 »»^^ 



One copy del. to Cat. Div, 



ICI9 



